12

var title_f6_12_6336="Measurement QT dispersion";
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" Measurement of QT dispersion",
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" <div class=\"lgnd\">",
" The measurement of QT dispersion may be based either on the real QRS duration
and or differences in the measurable duration of QT intervals. As shown, two
hypothetical T waves of the same amplitude can have different offset when the heart
vector becomes perpendicular to the axis of one of the leads; this results in real
dispersion of the QT intervals (vertical dashed lines). However, if different
proportion of the final part of the two T waves is below the threshold level (eg
with an automatic threshold method) the measured dispersion of the QT intervals
(vertical solid line) is different from the real dispersion.",
" <div class=\"footnotes\">",
" </div>",
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var title_f6_12_6337="Treatment protocols for renal cell cancer";
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JavaScript is required in order for our site to behave correctly. Please enable
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src=\"./../images/logoWKH.myextg\" width=\"175\">",
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" Official reprint from UpToDate",
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" <div id=\"topicContent\">",
" <div id=\"topicTitle\">",
" Treatment protocols for renal cell cancer",
" </div>",
" <div id=\"topicContributors\">",
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" <a id=\"authors\">",
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" Authors",
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" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
6/12/6337/contributors\">",
" Tim Brenner, PharmD, BCOP",
" </a>",
" <br/>",
" Shrina Duggal, PharmD, BCOP",
" </a>",
" <br/>",
" Jim Natale, PharmD, BCOP",
" </a>",
" <br/>",
" Scott M Wirth, PharmD, BCOP",
" </a>",
" <br/>",
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" <div>",
" Section Editor",
" </a>",
" <br/>",
" John W Mucenski, PharmD",
" </a>",
" <br/>",
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" <div>",
" Deputy Editor",
" </a>",
" <br/>",
" Don S Dizon, MD, FACP",
" </a>",
" <br/>",
" </div>",
" </div>",
" <div id=\"disclosures\">",
" <a href=\"UTD.htm?6/12/6337/contributor-disclosure\" target=\"_blank\">",
" Disclosures",
" </a>",
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" <div id=\"reviewProcess\">",
" <span>",
" All topics are updated as new evidence becomes available and our",
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" Literature review current through:",
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" <p class=\"headingAnchor\" id=\"H12047318\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" — The following material represents a subset of chemotherapy
regimens that are used for the treatment of patients with advanced renal cell
cancer.",
" <strong>",
" This is",
" </strong>",
" <strong>",
" not an exhaustive list.",
" </strong>",
" Additional regimens may be added over time, particularly as treatment for
renal cell cancer evolves.",
" </p>",
" <p>",
" This topic review does not address the appropriate context for use of these
regimens in the care of patients with renal cell cancer. Clinicians should refer to
the individual disease-oriented topic reviews that discuss the use of these
protocols in appropriate clinical situations:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?27/32/28170?
source=see_link&anchor=H27#H27\">",
" \"Anti-angiogenic and molecularly targeted therapy for advanced renal cell
carcinoma\", section on 'Temsirolimus'",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p>",
" These tables are provided as examples of how to administer these regimens;
there may be other acceptable methods. All protocols must be administered by
clinicians who are trained in the use of chemotherapy. The clinician is expected to
use his or her independent medical judgment in the context of individual
circumstances to make adjustments, as necessary.",
" </p>",
" REGIMENS",
" </span>",
" </p>",
" Advanced or metastatic renal cell carcinoma",
" </span>",
" </p>",
" Temsirolimus",
" </span>",
" — (",
" <a class=\"graphic graphic_table graphicRef68554 \" href=\"UTD.htm?
17/4/17485\">",
" table 1",
" </a>",
" )",
" </p>",
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var outline_f6_12_6337=[" <div id=\"toggleOutline\">",
" <a href=\"#\" title=\"Collapse Topic Outline\">",
" <img alt=\"\" src=\"./../images/orange_arrow_left.myextg\"/>",
" </a>",
" </div>",
" <div id=\"innerOutline\">",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <div id=\"outline\">",
" <ul>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H12047318\">",
" INTRODUCTION",
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" <h1>",
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" GRAPHICS",
" <a class=\"graphics_icon\" href=\"#\" title=\"View All Related Graphics\">",
" View All",
" </a>",
" </div>",
" </h1>",
" <div id=\"relatedGraphics\">",
" <ul>",
" <div class=\"openRelatedGraphics\" id=\"ONC/85691|TAB\">",
" <a href=\"#\" title=\"TABLES\">",
" TABLES",
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1\">",
" IV temsirolimus regimen",
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" <h1>",
" RELATED TOPICS",
" </h1>",
" <div id=\"relatedTopics\">",
" <ul>",
source=related_link\">",
" Anti-angiogenic and molecularly targeted therapy for advanced renal cell
carcinoma",
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var title_f6_12_6338="HS abscess";
" ©2013 UpToDate",
" <sup>",
" ®",
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" </div>",
" <a href=\"?imageKey=DERM
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" Hidradenitis suppurativa with an abscess",
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",
" </div>",
" </div>",
" Reproduced with permission from: F William Danby, MD, FRCPC, FAAD and
Lynne J Margesson, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6339="Interactive diabetes case 14: A 41-year-old man with type 2
diabetes and hypertriglyceridemia";
" </div>",
" </noscript>",
" <br>",
" <sup>",
" ®",
" </sup>",
" <br>",
" </a>",
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </br>",
" </div>",
" </br>",
" </img>",
" </img>",
" </div>",
here to print\">",
" Print",
" </a>",
" |",
" </span>",
" Back",
" </a>",
" </div>",
" </div>",
" Interactive diabetes case 14: A 41-year-old man with type 2 diabetes and
hypertriglyceridemia",
" </div>",
" <div>",
" </a>",
" Author",
" </a>",
" <br/>",
" Lloyd Axelrod, MD",
" </a>",
" <br/>",
" </div>",
" <div>",
" Section Editor",
" </a>",
" <br/>",
" David M Nathan, MD",
" </a>",
" <br/>",
" </div>",
" <div>",
" Deputy Editor",
" </a>",
" <br/>",
" Jean E Mulder, MD",
" </a>",
" <br/>",
" </div>",
" </div>",
" Disclosures",
" </a>",
" </div>",
" <span>",
" </span>",
" </a>",
" <span>",
" is complete.",
" </span>",
" </div>",
" </span>",
" Oct 2013.",
" |",
" </span>",
" </span>",
" Nov 6, 2012.",
" </div>",
" CASE",
" </span>",
" — You are asked to evaluate and manage a 41-year-old man with
type 2 diabetes who was recently noted to have a triglyceride level of 1118",
" <span class=\"nowrap\">",
" mg/dL",
" </span>",
" on routine lipid evaluation.",
" </p>",
" <p>",
" Three years ago the patient had the following fasting laboratory values,
obtained on a routine basis because of obesity: glucose 102",
" mg/dL",
" </span>",
" (5.66",
" mmol/L),",
" </span>",
" total cholesterol 209",
" mg/dL,",
" </span>",
" triglycerides 394",
" mg/dL,",
" </span>",
" HDL cholesterol 33",
" mg/dL,",
" </span>",
" LDL cholesterol 116",
" mg/dL.",
" </span>",
" </p>",
" <p>",
" Two and a half years ago, the patient had a fasting blood glucose level of
138",
" mg/dL",
" </span>",
" (7.66",
" mmol/L).",
" </span>",
" An A1C value a few days later was 7.1 percent. The patient was told that he
has type 2 diabetes and met with a nutritionist for medical nutrition therapy.",
" </p>",
" <p>",
" His efforts to reduce weight were unsuccessful despite regular visits to his
clinician. Two years ago, he was started on",
" <a class=\"drug drug_general\" href=\"UTD.htm?7/48/7944?source=see_link\">",
" metformin",
" </a>",
" with doses titrated to 1000 mg twice a day.",
" Repaglinide",
" </a>",
" was added soon thereafter, with doses titrated to 4 mg three times daily
before meals. One month before his visit to you, his fasting laboratory values were
as follows: glucose 173",
" mg/dL",
" </span>",
" (9.6",
" mmol/L),",
" </span>",
" A1C 8.9 percent, total cholesterol 231",
" mg/dL,",
" </span>",
" triglycerides 1118",
" mg/dL,",
" </span>",
" and HDL cholesterol 36",
" mg/dL.",
" </span>",
" The LDL cholesterol was not calculated by the laboratory because these
calculations are inaccurate when the triglyceride level exceeds approximately 400",
" mg/dL.",
" </span>",
" </p>",
" <p>",
" The patient eats out in restaurants three times a week, where he has 16-ounce
portions of untrimmed red meat with a baked potato. He has two eggs with two
sausages for breakfast three times a week, does not drink milk, and consumes about
a quarter of a pound of cheese once a week. He states that he knows he can do
better with his diet and is determined to do so.",
" </p>",
" <p>",
" He does not drink alcoholic beverages currently, although he acknowledges \"a
drinking problem\" when he was younger, and does not smoke. He is sedentary at work
and does not exercise. He has hypertension treated with",
" ramipril",
" </a>",
" 20 mg a day. His other medications include calcium 600 mg with vitamin D 400
Units twice daily. He has no known heart disease.",
" </p>",
" <p>",
" On examination, he weighs 217 lbs and is 5 feet 5 inches tall, with a body
mass index of 36.1. The blood pressure is",
" 120/80",
" </span>",
" right arm supine,",
" 130/90",
" </span>",
" right arm upright. On physical examination there is no evidence of
retinopathy, neuropathy, or peripheral artery disease. The BUN is 18",
" mg/dL,",
" </span>",
" the serum creatinine is 1.2",
" mg/dL,",
" </span>",
" and the urine",
" microalbumin/creatinine",
" </span>",
" ratio is 6.4",
" mg/g.",
" </span>",
" The TSH level is 1.8",
" microunits/dL.",
" </span>",
" </p>",
" <p>",
" You confirm in an individual discussion with the patient's wife that he no
longer consumes alcoholic beverages in any amount.",
" </p>",
" <p>",
" What is your assessment and plan?",
" </p>",
" <p>",
" <li>",
" You conclude that the patient has mixed hyperlipidemia based on the total
cholesterol and triglyceride levels, and that the HDL level is below recommended
values for a male patient. You conclude that he is at high risk for cardiovascular
disease because of his lipid levels, diabetes, and hypertension.",
" <br/>",
" <br/>",
" You advise him to limit his red meat intake to smaller portions (eg, 4 or 5
ounces), trimmed to remove the fat and consumed less frequently; to use a low fat
sausage substitute and an egg substitute instead of eggs; to reduce portions at
meals including those of carbohydrates; and to eliminate drinks with concentrated
carbohydrates such as regular sodas and fruit juices. You encourage him to eat fish
at least twice a week.",
" <br/>",
" <br/>",
" You refer him to a nutritionist to review his diet. You advise him to begin
walking at least five days a week, gradually increasing the duration to at least 35
minutes a day. You start him on a statin for cardiovascular risk prevention,
using",
" <a class=\"drug drug_general\" href=\"UTD.htm?34/37/35417?
source=see_link\">",
" atorvastatin",
" </a>",
" 10 mg in the evening. You advise him to take",
" aspirin",
" </a>",
" 81 mg a day. You consider adding a fibric acid derivative at a later time.
(See",
" <a class=\"medical medical_answer\" href=\"UTD.htm?6/12/6339-a1?
" \"Interactive diabetes case 14: A 41-year-old man with type 2 diabetes and
hypertriglyceridemia - A1\"",
" </a>",
" .)",
" </li>",
" <li>",
" You conclude that the patient probably has acute pancreatitis based on his
triglyceride level. You order stat levels of amylase and lipase and a white blood
count and differential count. You obtain abdominal x-rays. You ask the patient to
remain in your office, anticipating admission to the hospital. (See",
" </a>",
" .)",
" </li>",
" <li>",
" You conclude that the patient has uncontrolled diabetes and that this may be
the reason for the rise in his triglyceride level over the last three years. You
note that the diabetes is uncontrolled despite a prolonged trial of medical
nutrition therapy and full doses of two oral agents for diabetes.",
" <br/>",
" <br/>",
" You are concerned that he may have an elevation of the LDL cholesterol above
recommended levels but conclude that this cannot be assessed satisfactorily until
the triglyceride level has been reduced markedly.",
" <br/>",
" <br/>",
" You are also concerned that the patient is at high risk for pancreatitis.
You order a white blood count and differential count, and levels of amylase and
lipase.",
" <br/>",
" <br/>",
" You advise him to limit his red meat intake to smaller portions (eg, 4 or 5
oz), trimmed to remove the fat and consumed less frequently; to use a low fat
sausage substitute and an egg substitute instead of eggs; to reduce portions at
meals including those of carbohydrates; and to eliminate drinks with concentrated
carbohydrates such as regular sodas and fruit juices. You encourage him to eat fish
at least twice a week. You refer him to a nutritionist to review his diet.",
" <br/>",
" <br/>",
" You advise him to begin walking at least five days a week, gradually
increasing the duration to at least 35 minutes a day. You advise him to take",
" aspirin",
" </a>",
" 81 mg a day. You inform him of the risk of acute pancreatitis, a painful and
life-threatening condition, if he does not reduce his triglyceride levels, and
advise him of the need for close medical follow-up in the near future. (See",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"PATIENT_INFORMATION\">",
" INFORMATION FOR PATIENTS",
" </span>",
" — UpToDate offers two types of patient education materials,
“The Basics” and “Beyond the Basics.” The Basics patient
education pieces are written in plain language, at the 5",
" <sup>",
" th",
" </sup>",
" to 6",
" <sup>",
" th",
" </sup>",
" grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10",
" <sup>",
" th",
" </sup>",
" to 12",
" <sup>",
" th",
" </sup>",
" grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.",
" </p>",
" <p>",
" Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)",
" </p>",
" <p>",
" <li>",
" Basics topics (see",
" <a class=\"medical medical_basics\" href=\"UTD.htm?32/44/33475?
" \"Patient information: Type 2 diabetes (The Basics)\"",
" </a>",
" and",
" \"Patient information: High cholesterol (The Basics)\"",
" </a>",
" )",
" </li>",
" <li>",
" Beyond the Basics topics (see",
" <a class=\"medical medical_patient\" href=\"UTD.htm?9/22/9572?
" \"Patient information: Diabetes mellitus type 2: Overview (Beyond the
Basics)\"",
" </a>",
" and",
" \"Patient information: Preventing complications in diabetes mellitus
(Beyond the Basics)\"",
" </a>",
" and",
" \"Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond
the Basics)\"",
" </a>",
" )",
" </li>",
" </ul>",
" </p>",
" </div>",
" </a>",
" .",
" </div>",
" </div>",
" </div>",
" </span>",
" |",
" </span>",
" </a>",
" |",
" </span>",
" Release: 21.6- C21.56",
" </span>",
" <br/>",
" Licensed to:",
" </span>",
" </span>",
" |",
" </span>",
" Support Tag: [1002-61.234.146.186-2A6F391156-S244013.14]",
" <br/>",
" </span>",
" </div>",
" </div>",
"</div>"].join("\n");
" </a>",
" </div>",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <ul>",
" CASE",
" </a>",
" </li>",
" <a class=\"outlineLink\" href=\"#PATIENT_INFORMATION\">",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <ul>",
hypertriglyceridemia - A1",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" Patient information: Diabetes mellitus type 2: Overview (Beyond the
Basics)",
" </a>",
" </li>",
" Patient information: High cholesterol (The Basics)",
" </a>",
" </li>",
" Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond
the Basics)",
" </a>",
" </li>",
" Patient information: Preventing complications in diabetes mellitus (Beyond
the Basics)",
" </a>",
" </li>",
" Patient information: Type 2 diabetes (The Basics)",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>"].join("\n");
var title_f6_12_6340="Pipingas technique for intraumbilical vein injection";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=OBGYN
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=OBGYN
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" Pipingas technique for intraumbilical vein injection",
" </div>",
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IzohTNvSQMxYxNG4M+0vNMIbjOJbjOabjOrbjO8bBf8XjPXYqjuXjP84szAXkQW4UHG3QFXYdhTXRsJVhKp
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lTtfRZdmMTW8eBndDW3CeV3Se1X3+Y8y16L8IAHxFToDT2Xe24AZ4h9Y1Osw6YAGtZ50tzmFIW432Z7LE6J
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uqu9uqvBuuwFuvcCwgAOw==);\">",
" </div>",
" The Pipingas technique. A naso-gastric tube is threaded down the umbilical
vein to the placental bed, and then withdrawn by 5 cm and tied. 30 mLs of solution
are then injected down the catheter.",
" </div>",
" Courtesy of Tim Signore.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6341="Insulin NPH and insulin regular: Patient drug information";
" </div>",
" </noscript>",
" <br>",
" <sup>",
" ®",
" </sup>",
" <br>",
" </a>",
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </br>",
" </div>",
" </br>",
" </img>",
" </img>",
" </div>",
here to print\">",
" Print",
" </a>",
" |",
" </span>",
" Back",
" </a>",
" </div>",
" </div>",
" <div id=\"disclaimer\">",
" The content on the UpToDate website is not intended nor recommended as a
substitute",
"for medical advice, diagnosis, or treatment. Always seek the advice of your own
physician or",
"other qualified health care professional regarding any medical questions or
conditions. The",
"use of this website is governed by the",
" <a href=\"/home/terms-use\" target=\"_blank\">",
" UpToDate Terms of Use",
" </a>",
" ©2013 UpToDate, Inc.",
" </div>",
" <div id=\"drugTitle\">",
" Insulin NPH and insulin regular: Patient drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <p>",
" (For additional information",
" see \"Insulin NPH and insulin regular: Drug information\"",
" </a>",
" and",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?6/46/6886?source=see_link\">",
" see \"Insulin NPH and insulin regular: Pediatric drug information\"",
" </a>",
" )",
" </p>",
" <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F2137923\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: U.S.",
" </span>",
" <ul>",
" <li>",
" HumuLIN® 70/30;",
" </li>",
" <li>",
" NovoLIN® 70/30",
" </li>",
" </ul>",
" </div>",
" <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F2186441\"
" Brand Names: Canada",
" </span>",
" <ul>",
" <li>",
" Humulin® 20/80;",
" </li>",
" <li>",
" Humulin® 70/30;",
" </li>",
" <li>",
" Novolin® ge 30/70;",
" </li>",
" <li>",
" Novolin® ge 40/60;",
" </li>",
" <li>",
" Novolin® ge 50/50",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yya-os drugH1Div\" id=\"F10018612\"
" What is this drug used for?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" •",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2691404",
" </span>",
" </span>",
" <span class=\"content\">",
" It is used to lower blood sugar in patients with high blood sugar
(diabetes).",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt coi-os drugH1Div\" id=\"F10018611\"
" What do I need to tell my doctor before I take this drug?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2702304",
" </span>",
" </span>",
" If you have an allergy to insulin or any other part of this drug.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2705171",
" </span>",
" </span>",
" If you are allergic to any drugs, foods, or other substances. Tell your
doctor about the allergy and what signs you had, like rash; hives; itching;
shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or
any other signs.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yye-os drugH1Div\" id=\"F10018616\"
" What are some things I need to know or do while I take this drug?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2699677",
" </span>",
" </span>",
" Keep a list of all your drugs (prescription, natural products, vitamins,
OTC) with you. Give this list to your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697780",
" </span>",
" </span>",
" Wear disease medical alert ID (identification).",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696820",
" </span>",
" </span>",
" Do not run out of this drug.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697009",
" </span>",
" </span>",
" If you are 80 or older, use this drug with care. You could be more
sensitive to low blood sugar.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697282",
" </span>",
" </span>",
" If you have kidney disease, talk with your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698422",
" </span>",
" </span>",
" Check your blood sugar as you have been told by your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698463",
" </span>",
" </span>",
" Have your blood work checked often. Talk with your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698495",
" </span>",
" </span>",
" Have an eye exam and visit the foot doctor every year.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696717",
" </span>",
" </span>",
" Check all drugs you are taking with your doctor. This drug may not mix well
with some other drugs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696750",
" </span>",
" </span>",
" Do not drive if your blood sugar has been low. There is a greater chance of
you having a crash.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697562",
" </span>",
" </span>",
" Limit your drinking of wine, beer, or mixed drinks.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696704",
" </span>",
" </span>",
" Keep workouts the same. More workouts may lower your insulin needs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697641",
" </span>",
" </span>",
" Tell your doctor if you are pregnant or plan on getting pregnant. You will
need to talk about the benefits and risks of using this drug while you are
pregnant.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697636",
" </span>",
" </span>",
" Tell your doctor if you are breast-feeding. You will need to talk about any
risks to your baby.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyf-os drugH1Div\" id=\"F10018617\"
" What are some side effects of this drug?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2698210",
" </span>",
" </span>",
" Low blood sugar may occur. Signs may be dizziness, headache, feeling
sleepy, feeling weak, shaking, a fast heartbeat, confusion, hunger, or sweating.
Keep hard candies, glucose tablets, liquid glucose, or juice on hand for low blood
sugar.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698272",
" </span>",
" </span>",
" Upset stomach or throwing up. Many small meals, good mouth care, sucking
hard, sugar-free candy, or chewing sugar-free gum may help.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698392",
" </span>",
" </span>",
" Weight gain.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698189",
" </span>",
" </span>",
" Irritation where the shot is given.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyh-os drugH1Div\" id=\"F10018619\"
" What are some side effects that I need to call my doctor about right away?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2698721",
" </span>",
" </span>",
" If you think there has been an overdose, call 1-800-222-1222 (the American
Association of Poison Control Centers), your local poison control center
(file://www.aapcc.org), or emergency room (ER) right away.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699066",
" </span>",
" </span>",
" Signs of an allergic reaction, like rash; hives; itching; red, swollen,
blistered, or peeling skin with or without fever; wheezing; tightness in the chest
or throat; trouble breathing or talking; unusual hoarseness; or swelling of the
mouth, face, lips, tongue, or throat.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699077",
" </span>",
" </span>",
" Signs of infection. These include a fever of 100.5°F (38°C) or
higher, chills, very bad sore throat, ear or sinus pain, cough, more sputum or
change in color of sputum, pain with passing urine, mouth sores, wound that will
not heal, or anal itching or pain.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699111",
" </span>",
" </span>",
" Very low blood sugar or very high blood sugar.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698603",
" </span>",
" </span>",
" Any rash.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698977",
" </span>",
" </span>",
" Side effect or health problem is not better or you are feeling worse.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyc-os drugH1Div\" id=\"F10018614\"
" How is this drug best taken?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2696185",
" </span>",
" </span>",
" Use as you have been told, even if you are feeling better.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699163",
" </span>",
" </span>",
" Do not use out dated insulin.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2807179",
" </span>",
" </span>",
" Do not mix this insulin in the same syringe with other types of insulin.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696001",
" </span>",
" </span>",
" It is given as a shot into the fatty part of the skin.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2695826",
" </span>",
" </span>",
" Take 30 minutes before a meal.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696118",
" </span>",
" </span>",
" Throw away needles in a needle/sharp disposal box and take the box back to
your doctor when it is full.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2694865",
" </span>",
" </span>",
" Follow the diet and workout plan that your doctor told you about.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyd-os drugH1Div\" id=\"F10018615\"
" What do I do if I miss a dose?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s3629482",
" </span>",
" </span>",
" Give a missed shot as soon as you think about it.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s3629483",
" </span>",
" </span>",
" If it is close to the time for your next shot, skip the missed shot and go
back to your normal time.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyi-os drugH1Div\" id=\"F10018620\"
" How do I store and/or throw out this drug?",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2699566",
" </span>",
" </span>",
" Store unopened containers in a refrigerator. Do not freeze.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s3528085",
" </span>",
" </span>",
" You may store opened vials at room temperature or in a refrigerator. If
stored at room temperature, throw away any part not used after 4 or 6 weeks as you
have been told.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699656",
" </span>",
" </span>",
" Store opened cartridges and pens at room temperature. Throw away any part
not used as you have been told by your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699284",
" </span>",
" </span>",
" Protect opened containers from heat.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699285",
" </span>",
" </span>",
" Protect opened containers from light.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyj-os drugH1Div\" id=\"F10018621\"
" General drug facts",
" </span>",
" •",
" </span>",
" urn:lims:b259:s2699675",
" </span>",
" </span>",
" If your symptoms or health problems do not get better or if they become
worse, call your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699673",
" </span>",
" </span>",
" Do not share your drugs with others and do not take anyone else's drugs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699678",
" </span>",
" </span>",
" Keep all drugs out of the reach of children and pets.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699709",
" </span>",
" </span>",
" If you have any questions about this drug, please talk with your doctor,
pharmacist, or other health care provider.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s3302581",
" </span>",
" </span>",
" In Canada, take any unused drugs to the pharmacy. Also, visit
file://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/disposal-defaire-eng.php#th to learn about
the right way to get rid of unused drugs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699677",
" </span>",
" </span>",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699671",
" </span>",
" </span>",
" These are not all of the side effects that may occur. If you have questions
about side effects, call your doctor. Call your doctor for medical advice about
side effects.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699683",
" </span>",
" </span>",
" Talk with the doctor before starting any new drug, including prescription
or OTC, natural products, or vitamins.",
" </span>",
" </li>",
" </ul>",
" </div>",
" </div>",
" </a>",
" .",
" </div>",
" </div>",
" </div>",
" </span>",
" |",
" </span>",
" </a>",
" |",
" </span>",
" Release: 21.6- C21.56",
" </span>",
" <br/>",
" Licensed to:",
" </span>",
" </span>",
" |",
" </span>",
" Support Tag: [0603-89.32.226.102-9F539080E8-S244013.14]",
" <br/>",
" </span>",
" </div>",
" </div>",
"</div>"].join("\n");
" </a>",
" </div>",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <ul>",
" <a class=\"outlineLink\" href=\"#F2137923\">",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <ul>",
" Insulin NPH and insulin regular: Drug information",
" </a>",
" </li>",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?6/46/6886?
" Insulin NPH and insulin regular: Pediatric drug information",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>"].join("\n");
var title_f6_12_6342="Aspirin: Patient drug information";
" </div>",
" </noscript>",
" <br>",
" <sup>",
" ®",
" </sup>",
" <br>",
" </a>",
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </br>",
" </div>",
" </br>",
" </img>",
" </img>",
" </div>",
here to print\">",
" Print",
" </a>",
" |",
" </span>",
" Back",
" </a>",
" </div>",
" </div>",
" <div id=\"disclaimer\">",
" The content on the UpToDate website is not intended nor recommended as a
substitute",
"for medical advice, diagnosis, or treatment. Always seek the advice of your own
physician or",
"other qualified health care professional regarding any medical questions or
conditions. The",
"use of this website is governed by the",
" <a href=\"/home/terms-use\" target=\"_blank\">",
" UpToDate Terms of Use",
" </a>",
" ©2013 UpToDate, Inc.",
" </div>",
" <div id=\"drugTitle\">",
" Aspirin: Patient drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <p>",
" (For additional information",
" see \"Aspirin: Drug information\"",
" </a>",
" and",
" see \"Aspirin: Pediatric drug information\"",
" </a>",
" )",
" </p>",
" <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F137093\"
" </span>",
" <ul>",
" <li>",
" Ascriptin® Maximum Strength [OTC];",
" </li>",
" <li>",
" Ascriptin® Regular Strength [OTC];",
" </li>",
" <li>",
" Aspercin [OTC];",
" </li>",
" <li>",
" Aspergum® [OTC];",
" </li>",
" <li>",
" Aspir-low [OTC];",
" </li>",
" <li>",
" Aspirtab [OTC];",
" </li>",
" <li>",
" Bayer® Aspirin Extra Strength [OTC];",
" </li>",
" <li>",
" Bayer® Aspirin Regimen Adult Low Strength [OTC];",
" </li>",
" <li>",
" Bayer® Aspirin Regimen Children's [OTC];",
" </li>",
" <li>",
" Bayer® Aspirin Regimen Regular Strength [OTC];",
" </li>",
" <li>",
" Bayer® Genuine Aspirin [OTC];",
" </li>",
" <li>",
" Bayer® Plus Extra Strength [OTC];",
" </li>",
" <li>",
" Bayer® Women's Low Dose Aspirin [OTC];",
" </li>",
" <li>",
" Buffasal [OTC];",
" </li>",
" <li>",
" Bufferin® Extra Strength [OTC];",
" </li>",
" <li>",
" Bufferin® [OTC];",
" </li>",
" <li>",
" Buffinol [OTC];",
" </li>",
" <li>",
" Ecotrin® Arthritis Strength [OTC];",
" </li>",
" <li>",
" Ecotrin® Low Strength [OTC];",
" </li>",
" <li>",
" Ecotrin® [OTC];",
" </li>",
" <li>",
" Halfprin® [OTC];",
" </li>",
" <li>",
" St Joseph® Adult Aspirin [OTC];",
" </li>",
" <li>",
" Tri-Buffered Aspirin [OTC]",
" </li>",
" </ul>",
" </div>",
" <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F137094\"
" </span>",
" <ul>",
" <li>",
" Asaphen;",
" </li>",
" <li>",
" Asaphen E.C.;",
" </li>",
" <li>",
" Entrophen®;",
" </li>",
" <li>",
" Novasen;",
" </li>",
" <li>",
" Praxis ASA EC 81 Mg Daily Dose",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt war-os drugH1Div\" id=\"F10017633\"
" Warning",
" </span>",
" •",
" </span>",
" urn:lims:b498:s2700201",
" </span>",
" </span>",
" Do not give children and teenagers aspirin for flu signs or chickenpox.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2700530",
" </span>",
" </span>",
" Stent patients: Talk with your heart doctor before stopping this drug, even
if told to do so by some other doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2700602",
" </span>",
" </span>",
" Sometimes drugs are not safe when you take them with certain other drugs.
Taking them together can cause bad side effects. This is one of those drugs. Be
sure to talk to your doctor about all the drugs you take.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yya-os drugH1Div\" id=\"F10017635\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2691456",
" </span>",
" </span>",
" It is used to stop heart attacks.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2691564",
" </span>",
" </span>",
" It is used to stop strokes.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2691607",
" </span>",
" </span>",
" It is used to ease pain, swelling, and fever.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2691733",
" </span>",
" </span>",
" It is used to treat arthritis.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2691861",
" </span>",
" </span>",
" It is used to treat gout attacks.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2692044",
" </span>",
" </span>",
" It is used to treat rheumatic fever.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2691573",
" </span>",
" </span>",
" It is used to protect bypass grafts and stents in the heart.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt coi-os drugH1Div\" id=\"F10017634\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2700957",
" </span>",
" </span>",
" Do not give to a child younger than 16 years of age for flu or chickenpox
signs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2701553",
" </span>",
" </span>",
" If you have an allergy to aspirin or any other part of this drug.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2705171",
" </span>",
" </span>",
" If you are allergic to any drugs, foods, or other substances. Tell your
doctor about the allergy and what signs you had, like rash; hives; itching;
shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or
any other signs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2703265",
" </span>",
" </span>",
" If you have any of these health problems: Asthma, bleeding problems, nose
polyps, or rhinitis.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2701061",
" </span>",
" </span>",
" If you are more than 24 weeks pregnant.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yye-os drugH1Div\" id=\"F10017639\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2699677",
" </span>",
" </span>",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697235",
" </span>",
" </span>",
" If you have had an ulcer or bleeding from your stomach or bowel, talk with
your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698463",
" </span>",
" </span>",
" Have your blood work checked often. Talk with your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696717",
" </span>",
" </span>",
" Check all drugs you are taking with your doctor. This drug may not mix well
with some other drugs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697622",
" </span>",
" </span>",
" Talk with your doctor before using products that have aspirin, blood
thinners, garlic, ginseng, ginkgo, ibuprofen or like products, pain drugs, or
vitamin E.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697633",
" </span>",
" </span>",
" Tell dentists, surgeons, and other doctors that you use this drug.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698562",
" </span>",
" </span>",
" Take good care of your teeth. See a dentist often.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697604",
" </span>",
" </span>",
" Stent patients: Talk with your heart doctor before stopping this drug for
any reason.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697795",
" </span>",
" </span>",
" You may bleed more easily. Be careful and avoid injury. Use a soft
toothbrush and an electric razor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696618",
" </span>",
" </span>",
" Avoid beer, wine, or mixed drinks.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697641",
" </span>",
" </span>",
" Tell your doctor if you are pregnant or plan on getting pregnant. You will
need to talk about the benefits and risks of using this drug while you are
pregnant.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697740",
" </span>",
" </span>",
" Use birth control that you can trust to stop pregnancy while taking this
drug.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697636",
" </span>",
" </span>",
" Tell your doctor if you are breast-feeding. You will need to talk about any
risks to your baby.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyf-os drugH1Div\" id=\"F10017640\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2697889",
" </span>",
" </span>",
" Belly pain or heartburn.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698272",
" </span>",
" </span>",
" Upset stomach or throwing up. Many small meals, good mouth care, sucking
hard, sugar-free candy, or chewing sugar-free gum may help.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2697901",
" </span>",
" </span>",
" Bleeding problems.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyh-os drugH1Div\" id=\"F10017642\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2698721",
" </span>",
" </span>",
" If you think there has been an overdose, call 1-800-222-1222 (the American
Association of Poison Control Centers), your local poison control center
(file://www.aapcc.org), or emergency room (ER) right away.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699066",
" </span>",
" </span>",
" Signs of an allergic reaction, like rash; hives; itching; red, swollen,
blistered, or peeling skin with or without fever; wheezing; tightness in the chest
or throat; trouble breathing or talking; unusual hoarseness; or swelling of the
mouth, face, lips, tongue, or throat.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698640",
" </span>",
" </span>",
" Trouble breathing.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699023",
" </span>",
" </span>",
" Very bad dizziness or passing out.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699058",
" </span>",
" </span>",
" Change in thinking clearly and with logic.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699031",
" </span>",
" </span>",
" Very bad headache.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699001",
" </span>",
" </span>",
" Ringing in ears.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698607",
" </span>",
" </span>",
" Black, tarry, or bloody stools.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698609",
" </span>",
" </span>",
" Blood in the urine.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699105",
" </span>",
" </span>",
" Any bruising or bleeding.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698603",
" </span>",
" </span>",
" Any rash.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2698977",
" </span>",
" </span>",
" Side effect or health problem is not better or you are feeling worse.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyc-os drugH1Div\" id=\"F10017637\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2696130",
" </span>",
" </span>",
" To gain the most benefit, do not miss doses.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2695914",
" </span>",
" </span>",
" Take with or without food. Take with food if it causes an upset stomach.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2695701",
" </span>",
" </span>",
" Swallow enteric-coated and long-acting products whole. Do not chew, break,
or crush.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2694604",
" </span>",
" </span>",
" Chewable tablet: Chew or crush well. Mix crushed tablet with food. Do not
swallow it whole.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696199",
" </span>",
" </span>",
" Use suppository rectally.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyd-os drugH1Div\" id=\"F10017638\"
" </span>",
" •",
" </span>",
" urn:lims:b498:s2696563",
" </span>",
" </span>",
" Take a missed dose as soon as you think about it.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696496",
" </span>",
" </span>",
" If it is close to the time for your next dose, skip the missed dose and go
back to your normal time.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696475",
" </span>",
" </span>",
" Do not take 2 doses at the same time or extra doses.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696540",
" </span>",
" </span>",
" Many times this drug is taken on an as needed basis.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2696457",
" </span>",
" </span>",
" Do not change the dose or stop this drug. Talk with the doctor.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyi-os drugH1Div\" id=\"F10017643\"
" </span>",
" urn:lims:b498:s2705490",
" </span>",
" </span>",
" <b>",
" <span style=\"text-decoration: underline\">",
" Oral:",
" </span>",
" </b>",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699336",
" </span>",
" </span>",
" Store at room temperature.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699264",
" </span>",
" </span>",
" Protect from light.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699266",
" </span>",
" </span>",
" Store in a dry place. Do not store in a bathroom.",
" </span>",
" </li>",
" urn:lims:b498:s2705560",
" </span>",
" </span>",
" <b>",
" <span style=\"text-decoration: underline\">",
" Suppository:",
" </span>",
" </b>",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699391",
" </span>",
" </span>",
" Store in a refrigerator. Do not freeze.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b498:s2699171",
" </span>",
" </span>",
" Do not use suppositories if they have a vinegar smell.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyj-os drugH1Div\" id=\"F10017644\"
" </span>",
" •",
" </span>",
" urn:lims:b259:s2699675",
" </span>",
" </span>",
" If your symptoms or health problems do not get better or if they become
worse, call your doctor.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699673",
" </span>",
" </span>",
" Do not share your drugs with others and do not take anyone else's drugs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699678",
" </span>",
" </span>",
" Keep all drugs out of the reach of children and pets.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699709",
" </span>",
" </span>",
" If you have any questions about this drug, please talk with your doctor,
pharmacist, or other health care provider.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s3302581",
" </span>",
" </span>",
" In Canada, take any unused drugs to the pharmacy. Also, visit
file://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/disposal-defaire-eng.php#th to learn about
the right way to get rid of unused drugs.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699677",
" </span>",
" </span>",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699671",
" </span>",
" </span>",
" These are not all of the side effects that may occur. If you have questions
about side effects, call your doctor. Call your doctor for medical advice about
side effects.",
" </span>",
" </li>",
" •",
" </span>",
" urn:lims:b259:s2699683",
" </span>",
" </span>",
" Talk with the doctor before starting any new drug, including prescription
or OTC, natural products, or vitamins.",
" </span>",
" </li>",
" </ul>",
" </div>",
" </div>",
" </a>",
" .",
" </div>",
" </div>",
" </div>",
" </span>",
" |",
" </span>",
" </a>",
" |",
" </span>",
" Release: 21.6- C21.56",
" </span>",
" <br/>",
" Licensed to:",
" </span>",
" </span>",
" |",
" </span>",
" Support Tag: [1003-201.211.0.116-C984CE7589-S244013.14]",
" <br/>",
" </span>",
" </div>",
" </div>",
"</div>"].join("\n");
" </a>",
" </div>",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <ul>",
" </a>",
" </li>",
" </a>",
" </li>",
" Warning",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <ul>",
" Aspirin: Drug information",
" </a>",
" </li>",
" Aspirin: Pediatric drug information",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>"].join("\n");
var title_f6_12_6343="Left subclavian artery GCA";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=RHEUM
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=RHEUM
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" Narrowing of the left subclavian artery in giant cell arteritis",
" </div>",
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" </div>",
" Angiogram of the left subclavian artery in GCA, showing several areas of
severe vascular narrowing but a proliferation of small blood vessels forming
excellent collateral circulation. The long, smooth arterial tapering in large-
vessel GCA is often not amenable to revascularization interventions, such as
angioplasty or stent placement. Those types of interventions are rarely
necessary.",
" <p>",
" ",
" </p>",
" </div>",
" Courtesy of John H Stone, MD, MPH.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6344="Elective noncardiac surgery after percutaneous coronary
intervention";
" </div>",
" </noscript>",
" <img alt=\"UpToDate\" src=\"./../images/wk_utd-rgb.myextg\" width=\"220px\">",
" </img>",
" </div>",
" <sup>",
" ®",
" </sup>",
" </a>",
" <br>",
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </br>",
" </div>",
here to print\">",
" Print",
" </a>",
" |",
" </span>",
" Back",
" </a>",
" </div>",
" </div>",
" Elective noncardiac surgery after percutaneous coronary intervention",
" </div>",
" <div>",
" </a>",
" Authors",
" </a>",
" <br/>",
" Donald Cutlip, MD",
" </a>",
" <br/>",
" Stephan Windecker, MD",
" </a>",
" <br/>",
" </div>",
" <div>",
" Section Editors",
" </a>",
" <br/>",
" Juan Carlos Kaski, MD, DM, DSc, FRCP, FESC, FACC",
" </a>",
" <br/>",
" Patricia A Pellikka, MD, FACC, FAHA, FASE",
" </a>",
" <br/>",
" </div>",
" <div>",
" Deputy Editor",
" </a>",
" <br/>",
" Gordon M Saperia, MD, FACC",
" </a>",
" <br/>",
" </div>",
" </div>",
" Disclosures",
" </a>",
" </div>",
" <span>",
" </span>",
" </a>",
" <span>",
" is complete.",
" </span>",
" </div>",
" </span>",
" Oct 2013.",
" |",
" </span>",
" </span>",
" Dec 6, 2012.",
" </div>",
" INTRODUCTION",
" </span>",
" — The management of antiplatelet therapy in patients who need
noncardiac surgery after percutaneous coronary intervention (PCI) with stenting
requires consideration of the competing risks of acute coronary events (ACS) with
premature cessation and bleeding with continuation of antiplatelet therapy. This is
an important clinical problem, as it is estimated that about 5 to 10 percent of
patients with coronary stents undergo noncardiac surgery within one year of stent
implantation [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6344/abstract/1-4\">",
" 1-4",
" </a>",
" ].",
" </p>",
" <p>",
" This topic will focus on the approach to patients scheduled to undergo
elective noncardiac surgery after PCI with stenting and who are taking dual
antiplatelet therapy (DAT). Patients who require urgent or emergent surgery or
those who receive balloon angioplasty are also discussed briefly. The approach to
antiplatelet therapy in patients scheduled for coronary artery bypass graft surgery
is presented separately. (See",
" \"Medical therapy to prevent complications after coronary artery bypass graft
surgery\", section on 'Preoperative aspirin'",
" </a>",
" and",
" \"Medical therapy to prevent complications after coronary artery bypass graft
surgery\", section on 'Platelet P2Y12 receptor blocker therapy'",
" </a>",
" .)",
" </p>",
" <p>",
" The larger discussion of the risk of coronary artery stent thrombosis, one of
the potential complications of discontinuing antiplatelet therapy prior to
noncardiac surgery, is found elsewhere. (See",
" \"Antiplatelet therapy after coronary artery stenting\"",
" </a>",
" and",
" \"Coronary artery stent thrombosis: Incidence and risk factors\"",
" </a>",
" .)",
" </p>",
" DEFINITIONS",
" </span>",
" — For this topic, major surgery is defined as any surgery for
which the surgeon might recommend the discontinuation of dual antiplatelet therapy
due to a concern for an increase in bleeding risk. Most studies that have evaluated
this issue have included patients scheduled to undergo peripheral arterial,
orthopedic, abdominal, or thoracic surgery, or radical prostatectomy, nephrectomy,
or cystectomy.",
" </p>",
" <p>",
" Dual antiplatelet therapy refers to the combination of",
" aspirin",
" </a>",
" plus a P2Y12 receptor blocker such as",
" clopidogrel",
" </a>",
" ,",
" prasugrel",
" </a>",
" , or",
" ticagrelor",
" </a>",
" .",
" </p>",
" <p>",
" Adverse perioperative outcomes include acute coronary syndromes (including
myocardial infarction), death, urgent revascularization, and bleeding. In some
studies, stent thrombosis is included as an outcome; stent thrombosis is often the
proximate cause of myocardial infarction or death.",
" </p>",
" DEATH, MI, STENT THROMBOSIS, AND REVASCULARIZATION",
" </span>",
" — For patients taking dual antiplatelet therapy (DAT) after
PCI who need to undergo noncardiac surgery, the risk of perioperative adverse
cardiac events such as myocardial infarction (MI), death, stent thrombosis, and the
need for urgent repeat revascularization is related to the premature cessation of
DAT, the prothrombotic state created by the surgery, or an interaction between the
two. Perioperative bleeding associated with the continuation of DAT is also
associated with an increased risk of perioperative cardiac events.",
" </p>",
" <p>",
" Observational studies suggest that patients who have undergone noncardiac
surgery within six weeks after stenting may have an increased risk of death or MI
[",
" 5-7",
" </a>",
" ]. These events are often due to stent thrombosis, which may be caused by the
premature discontinuation or reduction of antiplatelet therapy, the thrombotic risk
associated with many forms of major surgery, or an interaction between the two.
Stent thrombosis can lead to high rates of myocardial infarction percent (50 to 70
percent) and death (10 to 40 percent), both of which are included as components of
composite outcomes in the studies discussed below [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6344/abstract/8\">",
" 8",
" </a>",
" ]. (See",
" <a class=\"local\" href=\"#H109480018\">",
" 'Timing and incidence'",
" </a>",
" below.)",
" </p>",
" Causes",
" </span>",
" </p>",
" Premature cessation of antiplatelet therapy",
" </span>",
" — In patients taking",
" aspirin",
" </a>",
" and a platelet P2Y12 receptor blocker after PCI, the premature cessation of
one or both agents is associated with an increase in adverse events such as stent
thrombosis, myocardial infarction, or death. In fact, the premature cessation of
dual antiplatelet therapy (and in particular the P2Y12 receptor blocker) is the
strongest predictor of stent thrombosis. (See",
" \"Coronary artery stent thrombosis: Incidence and risk factors\", section on
'Risk factors'",
" </a>",
" .)",
" </p>",
" Prothrombotic and proinflammatory effects of surgery",
" </span>",
" — The prothrombotic and proinflammatory effects of surgery
may predispose the coronary circulation to thrombosis, both at the site of prior
stent placement and at other sites of atherosclerotic lesions [",
" 9-12",
" </a>",
" ]. The perioperative prothrombotic state may be mediated by increased platelet
aggregation and decreased fibrinolysis [",
" 13-15",
" </a>",
" ].",
" </p>",
" Timing and incidence",
" </span>",
" — The following observations regarding the timing and
incidence of adverse outcomes following the premature discontinuation of
antiplatelet therapy help inform our recommendations for managing antiplatelet
therapy in patient who require noncardiac surgery:",
" </p>",
" <p>",
" <li>",
" In patients with stable coronary artery disease,",
" aspirin",
" </a>",
" is recommended indefinitely to prevent recurrent cardiovascular events and
discontinuation of aspirin has been estimated to be responsible for at least 15
percent of all recurrent events in this population [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6344/abstract/16,17\">",
" 16,17",
" </a>",
" ]. (See",
" \"Benefits and risks of aspirin in secondary and primary prevention of
cardiovascular disease\", section on 'Secondary prevention of CVD'",
" </a>",
" and",
" \"Perioperative medication management\", section on 'Aspirin'",
" </a>",
" .)",
" </li>",
" <li>",
" Patients who have received either bare-metal (BMS) or drug-eluting stents
(DES) receive dual antiplatelet therapy to prevent coronary artery stent
thrombosis. Most cases of ST occur within the first 30 days after placement,
irrespective of stent type. The cumulative rate of ST is similar for both bare
metal and most drug-eluting stents at up to five years. At one year, the cumulative
incidence is slightly greater than one percent. (See",
" \"Coronary artery stent thrombosis: Incidence and risk factors\", section
on 'Timing and incidence'",
" </a>",
" .)",
" </li>",
" <li>",
" As mentioned above, premature cessation of dual antiplatelet therapy is the
major predictor of stent thrombosis, irrespective of stent type. The risk has been
estimated to be 30- to 50-fold or greater. In patients who stop both agents, stent
thrombosis generally occurs within 10 days in the majority of patients who develop
this complication. For those patients who stop only the platelet P2Y12 receptor
blocker, the median time to ST is in excess of 100 days. (See",
on 'Early and late stent thrombosis'",
" </a>",
" and",
on 'Timing and incidence'",
" </a>",
" and",
" \"Antiplatelet therapy after coronary artery stenting\", section on 'Drug-
eluting stents'",
" </a>",
" .)",
" </li>",
" <li>",
" Observational studies have shown that patients who undergo major noncardiac
surgery within six weeks, and particularly within two weeks, of PCI with bare-metal
(BMS) or drug-eluting stents (DES) have an increased risk of adverse cardiovascular
events [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6344/abstract/1,5-7,18,19\">",
" 1,5-7,18,19",
" </a>",
" ]. This increased risk extends for as long as six months after DES
placement. These events are often due to stent thrombosis, which may be caused by
the premature discontinuation or reduction of antiplatelet therapy to minimize
bleeding risk, the thrombotic risk associated with many forms of major surgery, or
an interaction between the two.",
" </li>",
" <li>",
" The best evidence of the risk of cardiovascular events in patients who have
received an intracoronary stent and who are undergoing noncardiac surgery come from
a cohort study of 8116 patients who underwent intermediate-to-high-risk elective
noncardiac surgery in Ontario, Canada and received coronary stents within 10 years
before surgery [",
" 20",
" </a>",
" ]. Of these, 34 percent underwent PCI within two years before surgery and
DES were used in 33 percent. Outcomes were analyzed by stent type and time from
surgery and were compared to 341,550 surgical patients who had not received PCI.
While the rates of preoperative platelet P2Y12 receptor blocker were assessed (use
varied between 37 and 90 percent depending on the type of stent used and the time
interval between PCI and surgery), analyses were not performed based whether the
drug was discontinued or not. The primary outcome was 30-day composite of
mortality, readmission for acute coronary syndrome, or repeat revascularization.",
" <br/>",
" <br/>",
" The following findings were noted:",
" </li>",
" </ul>",
" </p>",
" <p>",
" <ul class=\"hyphen-block\">",
" <li>",
" For the 8116 surgical patients who underwent PCI within 10 years, the
primary outcome occurred in 2.1 percent. This rate was comparable to that of
intermediate risk individuals who had never received PCI. Intermediate risk was
defined using the Revised Cardiac Risk Index [",
" 19",
" </a>",
" ]. (See",
" \"Estimation of cardiac risk prior to noncardiac surgery\", section on
'Revised cardiac risk index'",
" </a>",
" .) ",
" </li>",
" <li>",
" When the interval between stent placement and surgery was less than 45 days,
the event rates for BMS and DES were very high at 6.7 and 20.0 percent
respectively. Comparing these patients operated on during this time interval to
those whose surgery was at least two years after PCI, the adjusted odds ratios [OR]
for 30-day events 2.35, 95% CI 0.98-5.64 and 11.58, 95% CI 4.08-32.80,
respectively.",
" </li>",
" <li>",
" When the interval was 45 to 180 days, the event rate for BMS and DES were
2.6 and approximately 4 percent, respectively. The adjusted OR were 1.06, 95% CI
0.58-1.92 and 1.71, 95% CI 0.73-4.01, respectively.",
" </li>",
" <li>",
" When the interval was 181 to 365 days, the event rate for DES was 1.2
percent (adjusted OR 0.64, 95% CI 0.20-2.04). Surprisingly, the event rate for BMS
increased to about 3.5 percent during this time period, perhaps due to an increased
rate of restenosis with BMS.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" Smaller retrospective observational studies have evaluated the risk and
timing of cardiovascular events at the time of noncardiac surgery. Conclusions from
these studies are generally consistent with the findings of the Ontario study
discussed above.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" In a study of 207 patients who underwent noncardiac surgery within two
months of bare metal stent (BMS) placement, eight had an adverse event (death, MI,
or stent thrombosis) and all occurred among the 168 patients (4.8 percent)
undergoing surgery within six weeks after stenting [",
" 6",
" </a>",
" ].",
" </li>",
" <li>",
" The risk of adverse events may be substantially greater when surgery is
performed within two weeks of BMS placement [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6344/abstract/5,7,18\">",
" 5,7,18",
" </a>",
" ]. In a report of 40 consecutive patients who underwent stent placement
between one and 39 days (average 13 days) before noncardiac surgery, there were six
cardiac deaths and one nonfatal MI (event rate 18 percent) [",
" 5",
" </a>",
" ]. There were also 11 bleeding complications, two of which were fatal. All
of the cardiac complications occurred in patients who underwent surgery less than
two weeks after stenting.",
" </li>",
" <li>",
" In a retrospective analysis of 192 patients with either BMS or DES placed as
long as two years before surgery, patients were divided into an early surgery group
(30 patients), in which surgery was performed when",
" clopidogrel",
" </a>",
" was still indicated according to labeling criteria, or a late surgery group
(162 patients) [",
" 18",
" </a>",
" ]. During the first 30 days after surgery, five patients (2.6 percent) died,
four of whom had documented coronary artery stent thrombosis. In 91 patients (47
percent), antiplatelet therapy was interrupted in the perioperative period and was
associated with a significantly higher death rate compared to those who continued
therapy (5.5 versus 0 percent). Four of the deaths occurred in the early surgery
group and one in the late surgery group. Within the early surgery group, 13
patients discontinued antiplatelet therapy, four of whom died. Within the late
surgery group, it could not be determined whether clopidogrel was stopped in the
one patient who died.",
" </li>",
" <li>",
" In a study of 1953 patients who received either BMS or DES and subsequently
underwent noncardiac surgery, there was no significant difference in the rate of
in-hospital mortality or ischemic cardiac events between the two types of stents
(13.3 versus 14.6 percent, respectively) [",
" 1",
" </a>",
" ]. These events occurred more frequently when surgery was performed within
42 days of stent implantation (42 versus 13 percent beyond 42 days) and when PCI
had been performed in the setting of an acute coronary syndrome (65 versus 32
percent).",
" </li>",
" </ul>",
" </p>",
" <p>",
" Despite the general consistency of the results of these four studies with the
Ontario study, they are limited by their small size, single center design, the use
of less complete and potentially less accurate data, and inclusion of emergency
cases in at least one study.",
" </p>",
" BLEEDING",
" </span>",
" — The risk of a serious complication related to perioperative
bleeding in patients taking one or two antiplatelet agents is not well studied,
except in patients undergoing coronary artery bypass graft surgery (CABG). In these
patients preoperative dual antiplatelet therapy increases that rate of bleeding as
well as the need for reoperation and transfusion. Given concerns for the need for
reoperation, discontinuation of P2Y12 receptor blocker at least five days before
surgery is recommended. (See",
" \"Early noncardiac complications of coronary artery bypass graft surgery\",
section on 'Bleeding'",
" </a>",
" .)",
" </p>",
" <p>",
" For non-CABG surgical patients,",
" aspirin",
" </a>",
" alone or with P2Y12 receptor blocker increases the risk of bleeding by as much
as 20 and 50 percent, respectively, and these rates are dependent on the location
of the surgery [",
" 21,22",
" </a>",
" ]. This excess bleeding leads to an increase in red blood cell transfusion,
but not to an increase in surgical mortality or morbidity. ",
" </p>",
" <p>",
" Despite the lack of definitive evidence of an increase in surgical mortality
or morbidity in patients taking dual antiplatelet therapy, many surgeons recommend
discontinuing P2Y12 receptor blocker before surgery. In some situations such as
neurosurgery, where the consequence of bleeding might be catastrophic, both",
" aspirin",
" </a>",
" and P2Y12 therapy are stopped.",
" </p>",
" OUR APPROACH",
" </span>",
" — The following discussion applies to patients scheduled to
undergo noncardiac surgery for whom it may be necessary to stop one or both
antiplatelet agents prior the recommended duration of such therapy. For these
patients, we and others believe that recommendations regarding the optimal timing
of elective noncardiac surgery after PCI with stenting as well as the optimal use
of antiplatelet therapy are based on low quality evidence [",
" 23",
" </a>",
" ].",
" </p>",
" <p>",
" The use of DAT should be made on a case by case basis, taking into account the
relative benefits and risks of continuing such therapy [",
" 24",
" </a>",
" ]. Prior to surgery, the patient, primary care physician, cardiologist,
anesthesiologist, and surgeon should be involved in decision making.",
" </p>",
" <p>",
" It should be kept in mind that the required duration of treatment with DAT for
the general population of patients who have undergone coronary stenting is much
shorter for BMS than DES, presumably due to the much shorter time required for
endothelialization of the stent with the former. Thus, DAT is recommended for at
one least month after BMS and for at least six months (or up to one year in
patients not at high risk of bleeding) after DES. When possible, we suggest
continuation of DAT for one year after both types of stents. (See",
" \"Antiplatelet therapy after coronary artery stenting\", section on 'Summary
and recommendations'",
" </a>",
" .)",
" </p>",
" Elective noncardiac surgery in stented patients",
" </span>",
" — In order to minimize adverse cardiovascular events, we
suggest that elective noncardiac surgery be deferred until after the minimal
recommended duration of dual antiplatelet therapy (DAT) for each type of stent. For
patients treated with either bare metal or drug-eluting stents who are not at high
risk of bleeding, we suggest one year of dual antiplatelet therapy. In patients at
high risk of bleeding, our recommended duration of therapy is one and six months,
respectively. (See",
" \"Antiplatelet therapy after coronary artery stenting\", section on 'Early
noncardiac surgery or gastrointestinal endoscopy'",
" </a>",
" .)",
" </p>",
" <p>",
" While the optimal duration of dual antiplatelet therapy for stented patients
is not known, we are concerned that the proinflammatory and prothrombotic risks of
surgery may increase the baseline risk of stent thrombosis even in the presence of
DAT if a significant percent of struts are not endothelialized. In addition, one
cannot predict the possibility that DAT might have to be stopped due to unexpected
major bleeding. Thus, we recommend caution in performing elective noncardiac
surgery prior to the minimal recommended duration of such therapy. Although the
minimal duration of such therapy is four weeks for BMS, we recommend waiting six
weeks given our concerns about the possible increased risk of stent thrombosis in
the perioperative period.",
" </p>",
" <p>",
" The final decision to continue or discontinue antiplatelet therapy in the
perioperative period should be made only after an informed discussion among the
surgeon, managing cardiologist (and other health care providers), and the patient
has taken place. Some surgeons are not fully aware of the risk of prematurely
discontinuing antiplatelet therapy in patients with recent PCI with stenting. In
many cases, DAT can be continued in the perioperative period, although for some
surgeries such as neurosurgery, posterior eye surgery, or prostatic surgery, the
risk of major bleeding may be greater than the risk of stent thrombosis.",
" </p>",
" <p>",
" Our recommendations for the timing of surgery are based on observations
presented above regarding the rates of stent thrombosis in patients with premature
cessation of DAT and rates of adverse cardiovascular events found in studies of
patients undergoing noncardiac surgery. (See",
" 'Timing and incidence'",
" </a>",
" above.) No randomized trials comparing different times for surgery after PCI
or differing antiplatelet strategies have been performed. These recommendations
attempt to take into account what is known about the risk of perioperative bleeding
on one or two antiplatelet agents.",
" </p>",
" <p>",
" If surgery must be performed before the minimum time period for dual
antiplatelet therapy (generally one year in patients not at high bleeding risk), we
suggest that an attempt be made to defer it for at least six weeks after placement
of a bare-metal stent and at least six months after a drug-eluting stent. In these
patients, a platelet P2Y12 receptor blocker should be discontinued for as brief a
period as possible.",
" Aspirin",
" </a>",
" should be continued through the perioperative period, since the risk of stent
thrombosis is further increased with the cessation of both aspirin and",
" clopidogrel",
" </a>",
" and surgery can usually be safely performed on aspirin. (See",
" </a>",
" .)",
" </p>",
" <p>",
" Additional points to consider include:",
" </p>",
" <p>",
" <li>",
" Minor surgical procedures and dental procedures do not require cessation of
antiplatelet therapy.",
" </li>",
" <li>",
" Clopidogrel",
" </a>",
" ,",
" prasugrel",
" </a>",
" , and",
" ticagrelor",
" </a>",
" should be stopped five, seven, and three days before surgery. Some experts
are willing to recommend shorter discontinuation periods, for procedures less
likely to be associated with major bleeding.",
" </li>",
" <li>",
" Clopidogrel",
" </a>",
" , if stopped, should be restarted with a loading dose of 300 mg as soon as
possible after surgery, perhaps even later in the day if postoperative bleeding has
stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to
effectiveness in the higher risk postoperative setting [",
" 25",
" </a>",
" ].",
" </li>",
" <li>",
" We suggest that surgery be performed in centers with 24-hour interventional
cardiology coverage [",
" 25",
" </a>",
" ]. (See",
" \"Management of cardiac risk for noncardiac surgery\", section on
'Preoperative PCI'",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" Urgent or emergent noncardiac surgery",
" </span>",
" — For patients who require surgery prior to the minimal
duration of dual antiplatelet therapy (DAT) discussed above, such as those who
require urgent or emergent noncardiac surgery, two issues need to be discussed
among all managing practitioners:",
" </p>",
" <p>",
" <li>",
" The relative risks and benefits of continuing DAT.",
" </li>",
" <li>",
" Role of platelet transfusion. For patients who are at increased risk of
bleeding, there will not be time to discontinue one or both antiplatelet agents.
While platelet transfusion may be necessary for excessive bleeding after surgery,
the role of prophylactic platelet transfusion has not been well studied. (See",
" \"Congenital and acquired disorders of platelet function\", section on
'Platelet transfusion'",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" Patients with prior balloon angioplasty",
" </span>",
" — Less than 5 percent of all PCIs are performed using balloon
angioplasty without stenting. In these patients, one month of DAT is generally
recommended. (See",
" \"Antithrombotic therapy for percutaneous coronary intervention: General
use\", section on 'Patients undergoing balloon angioplasty'",
" </a>",
" .)",
" </p>",
" <p>",
" There are no high quality studies that address the optimal approach to these
patients who need noncardiac surgery. If possible, we and others suggest waiting at
least 14 days before performing surgery [",
" 26",
" </a>",
" ]. For patients who must undergo surgery in a shorter time frame, and in
particular when antiplatelet therapy must be stopped (eg, neurosurgical
procedures), we suggest deferring surgery for at least 48 hours after balloon
angioplasty.",
" </p>",
" RECOMMENDATIONS OF OTHERS",
" </span>",
" — Our recommendations for patients with coronary stents
undergoing noncardiac surgery are generally consistent with those from the American
College of Chest Physicians, American College of Cardiology, and the European
Society of Cardiology [",
" 26-29",
" </a>",
" ].",
" </p>",
" POTENTIAL ALTERNATIVES TO DUAL ANTIPLATELET THERAPY",
" </span>",
" — The concept of bridging a gap in platelet P2Y12 receptor
blocker therapy using an intravenous glycoprotein",
" IIb/IIIa",
" </span>",
" inhibitor such as",
" tirofiban",
" </a>",
" or",
" eptifibatide",
" </a>",
" is under investigation [",
" 30,31",
" </a>",
" ]. Some academic medical centers have used such a bridging strategy in
patients at high risk of stent thrombosis [",
" 32",
" </a>",
" ].",
" </p>",
" <p>",
" Ticagrelor",
" </a>",
" has a shorter clinical half life than",
" clopidogrel",
" </a>",
" or",
" prasugrel",
" </a>",
" , and can be stopped 48 to 72 hours before surgery. Its role as a substitute
for these other P2Y12 receptor blockers in this setting has not been evaluated.",
" </p>",
" <p>",
" Parenteral anticoagulants such as",
" heparin",
" </a>",
" do not decrease the risk of stent thrombosis and should not be used as a
substitute to antiplatelet therapy.",
" </p>",
" SUMMARY AND RECOMMENDATIONS",
" </span>",
" </p>",
" <p>",
" <li>",
" Noncardiac surgery is often required in patients taking dual antiplatelet
therapy (DAT) after percutaneous coronary intervention (PCI) with stenting.
Cessation of DAT prior to the recommended duration of its use as well as the
prothrombotic and proinflammatory state associated with surgery contribute to an
increased risk of adverse cardiovascular events such as stent thrombosis,
myocardial infarction, or death. On the other hand, for some patients such as those
undergoing neurosurgical procedures, the risk of bleeding attributable to DAT may
be greater than the risk of an adverse cardiovascular event off such therapy.
(See",
" 'Introduction'",
" </a>",
" above and",
" 'Death, MI, stent thrombosis, and revascularization'",
" </a>",
" above.)",
" </li>",
" <li>",
" The following are our recommendations for patients taking DAT after PCI with
stenting for whom elective noncardiac surgery is needed. The rationale for the
durations presented below is given above (see",
" 'Elective noncardiac surgery in stented patients'",
" </a>",
" above):",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" We suggest deferring surgery for at least one year, as opposed to operating
sooner, irrespective of stent type (",
" <a class=\"grade\" href=\"._grade_6?title=Grade 2C\">",
" Grade 2C",
" </a>",
" ).",
" </li>",
" <li>",
" In patients who cannot wait at least one year for noncardiac surgery, we
recommend that an attempt be made to defer surgery for at least six weeks after
placement of a bare-metal stent and at least six months after a drug-eluting stent
(",
" <a class=\"grade\" href=\"._grade_2?title=Grade 1B\">",
" Grade 1B",
" </a>",
" ).",
" </li>",
" <li>",
" For most patients undergoing noncardiac surgery who are taking DAT after PCI
with stenting because they have not reached the recommended duration of such
therapy, we suggest continuing DAT, as opposed to stopping it prior to surgery (",
" Grade 2C",
" </a>",
" ).",
" <br/>",
" <br/>",
" In patients for whom the risk of bleeding is likely to exceed the risk of a
perioperative event due to the premature cessation of DAT, it is reasonable to
discontinue one antiplatelet agent. In patients for whom a bleeding complication
could be catastrophic, such as patients undergoing neurosurgical, prostate, or
posterior eye procedures, stopping both antiplatelet agents might be reasonable.
",
" </li>",
" </ul>",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" For patients taking DAT after PCI with balloon angioplasty who are scheduled
to undergo elective noncardiac surgery, we suggest waiting at least 14 days after
PCI (",
" Grade 2C",
" </a>",
" ). (See",
" 'Patients with prior balloon angioplasty'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" Recommendations for patients taking long-term",
" aspirin",
" </a>",
" monotherapy undergoing noncardiac surgery and for patients undergoing
coronary artery bypass graft surgery on DAT are found elsewhere. (See",
" </a>",
" and",
" \"Medical therapy to prevent complications after coronary artery bypass
graft surgery\", section on 'Preoperative aspirin'",
" </a>",
" and",
" \"Medical therapy to prevent complications after coronary artery bypass
graft surgery\", section on 'Platelet P2Y12 receptor blocker therapy'",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" </div>",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
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" Li N, Astudillo R, Ivert T, Hjemdahl P. Biphasic pro-thrombotic and
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" Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation
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" Mahla E, Lang T, Vicenzi MN, et al. Thromboelastography for monitoring
prolonged hypercoagulability after major abdominal surgery. Anesth Analg 2001;
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" Samama CM, Thiry D, Elalamy I, et al. Perioperative activation of hemostasis
in vascular surgery patients. Anesthesiology 2001; 94:74.",
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" Beving H, Zhao C, Albåge A, Ivert T. Abnormally high platelet activity
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" Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following
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" Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and
meta-analysis on the hazards of discontinuing or not adhering to aspirin among
50,279 patients at risk for coronary artery disease. Eur Heart J 2006; 27:2667.",
" </a>",
" </li>",
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" Schouten O, van Domburg RT, Bax JJ, et al. Noncardiac surgery after coronary
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with an increase in major adverse cardiac events. J Am Coll Cardiol 2007; 49:122.",
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" Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective
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" Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major
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Circulation 2012; 126:1355.",
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" Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the
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" </a>",
" </li>",
" <li>",
" Task Force on Myocardial Revascularization of the European Society of
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W, et al. Guidelines on myocardial revascularization. Eur Heart J 2010; 31:2501.",
" </a>",
" </li>",
" <li>",
" Savonitto S, D'Urbano M, Caracciolo M, et al. Urgent surgery in patients
with a recently implanted coronary drug-eluting stent: a phase II study of
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" </a>",
" </li>",
" <li>",
" Rassi AN, Blackstone E, Militello MA, et al. Safety of \"bridging\" with
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surgery. Am J Cardiol 2012; 110:485.",
" </a>",
" </li>",
" <li>",
" Huang PH, Croce KJ, Bhatt DL, Resnic FS. Recommendations for management of
antiplatelet therapy in patients undergoing elective noncardiac surgery after
coronary stent implantation. Crit Pathw Cardiol 2012; 11:177.",
" </a>",
" </li>",
" </ol>",
" </div>",
" </div>",
" </div>",
" </span>",
" |",
" </span>",
" </a>",
" |",
" </span>",
" Release: 21.3 - C21.34",
" </span>",
" <br/>",
" Licensed to:",
" Morehouse School of Medicine",
" </span>",
" </span>",
" |",
" </span>",
" Support Tag: [0502-210.101.131.232-9BEAA163C5-S473950.14]",
" <br/>",
" </span>",
" </div>",
" </div>",
"</div>"].join("\n");
" </a>",
" </div>",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <ul>",
" <li>",
" <a class=\"sr_button\" href=\"#H350963112\" id=\"summRecButton\">",
" <span>",
" SUMMARY & RECOMMENDATIONS",
" </span>",
" </a>",
" </li>",
" INTRODUCTION",
" </a>",
" </li>",
" DEFINITIONS",
" </a>",
" </li>",
" DEATH, MI, STENT THROMBOSIS, AND REVASCULARIZATION",
" </a>",
" </li>",
" Causes",
" </a>",
" </li>",
" - Premature cessation of antiplatelet therapy",
" </a>",
" </li>",
" - Prothrombotic and proinflammatory effects of surgery",
" </a>",
" </li>",
" Timing and incidence",
" </a>",
" </li>",
" BLEEDING",
" </a>",
" </li>",
" OUR APPROACH",
" </a>",
" </li>",
" Elective noncardiac surgery in stented patients",
" </a>",
" </li>",
" Urgent or emergent noncardiac surgery",
" </a>",
" </li>",
" Patients with prior balloon angioplasty",
" </a>",
" </li>",
" RECOMMENDATIONS OF OTHERS",
" </a>",
" </li>",
" POTENTIAL ALTERNATIVES TO DUAL ANTIPLATELET THERAPY",
" </a>",
" </li>",
" </a>",
" </li>",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <ul>",
" Antiplatelet therapy after coronary artery stenting",
" </a>",
" </li>",
" Antithrombotic therapy for percutaneous coronary intervention: General use",
" </a>",
" </li>",
" Benefits and risks of aspirin in secondary and primary prevention of
cardiovascular disease",
" </a>",
" </li>",
" Congenital and acquired disorders of platelet function",
" </a>",
" </li>",
" Coronary artery stent thrombosis: Incidence and risk factors",
" </a>",
" </li>",
" Early noncardiac complications of coronary artery bypass graft surgery",
" </a>",
" </li>",
" Estimation of cardiac risk prior to noncardiac surgery",
" </a>",
" </li>",
" Management of cardiac risk for noncardiac surgery",
" </a>",
" </li>",
" Medical therapy to prevent complications after coronary artery bypass graft
surgery",
" </a>",
" </li>",
" Perioperative medication management",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>"].join("\n");
var title_f6_12_6345="Necrotizing GN";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=NEPH
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=NEPH
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic2\" style=\"width: 1040px;\">",
" Necrotizing glomerulonephritis",
" </div>",
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" </div>",
" Light micrograph showing fresh segmental necrotizing lesions with bright red
fibrin deposition (arrows). A necrotizing glomerulonephritis can be seen in a
variety of inflammatory disorders including vasculitis and lupus nephritis. The
latter has prominent immune complex deposition which is generally absent in
vasculitis.",
" </div>",
" Courtesy of Helmut Rennke, MD.",
" </div>",
" </div>",
" </div>",
" Normal glomerulus",
" </div>",
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" </div>",
" Light micrograph of a normal glomerulus. There are only 1 or 2 cells per
capillary tuft, the capillary lumens are open, the thickness of the glomerular
capillary wall (long arrow) is similar to that of the tubular basement membranes
(short arrow), and the mesangial cells and mesangial matrix are located in the
central or stalk regions of the tuft (arrows).",
" </div>",
" Courtesy of Helmut G Rennke, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6346="Overview of illicit drug use in pregnant women";
" </div>",
" </noscript>",
" <br>",
" <sup>",
" ®",
" </sup>",
" <br>",
" </a>",
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </br>",
" </div>",
" </br>",
" </img>",
" </img>",
" </div>",
here to print\">",
" Print",
" </a>",
" |",
" </span>",
" Back",
" </a>",
" </div>",
" </div>",
" Overview of illicit drug use in pregnant women",
" </div>",
" <div>",
" </a>",
" Author",
" </a>",
" <br/>",
" Grace Chang, MD, MPH",
" </a>",
" <br/>",
" </div>",
" <div>",
" Section Editor",
" </a>",
" <br/>",
" Charles J Lockwood, MD",
" </a>",
" <br/>",
" </div>",
" <div>",
" Deputy Editor",
" </a>",
" <br/>",
" Vanessa A Barss, MD",
" </a>",
" <br/>",
" </div>",
" </div>",
" Disclosures",
" </a>",
" </div>",
" <span>",
" </span>",
" </a>",
" <span>",
" is complete.",
" </span>",
" </div>",
" </span>",
" Oct 2013.",
" |",
" </span>",
" </span>",
" Jan 22, 2013.",
" </div>",
" INTRODUCTION",
" </span>",
" — The obstetrical provider is in a key position for
screening, early diagnosis, counseling, and initiating treatment of pregnant women
who use illicit drugs",
" (marijuana/hashish,",
" </span>",
" cocaine, heroin, hallucinogens, inhalants, methamphetamine, prescription
psychotherapeutics used non-medically) [",
" 1",
" </a>",
" ]. Both the gravida and her family benefit from factual, nonjudgmental
information about the maternal and fetal risks of substance use and from counseling
about options for cessation. However, substance users may not seek prenatal care
because of fear, guilt and shame, as well as concerns about medical and legal
intervention [",
" 2",
" </a>",
" ]. Opioid users may not even realize that they are pregnant if they are not
planning pregnancy and misinterpret the early signs of pregnancy as opioid
withdrawal symptoms (eg, nausea, vomiting, cramping). Unintended pregnancy is
common in these women; in one study, 86 percent of pregnant opioid-using women
reported their pregnancy was unintended [",
" 3",
" </a>",
" ].",
" </p>",
" <p>",
" Pregnant women are typically highly motivated to modify their behavior in
order to help their unborn child. In a national survey from the United States, the
mean rate of pregnancy-related abstinence among users of illicit drugs was 57
percent [",
" 4",
" </a>",
" ]. Unfortunately, many of these women resumed substance use during the year
after giving birth, although not to the level of nonpregnant women who were not
recent mothers.",
" </p>",
" DEFINITIONS",
" </span>",
" — The following terms are used to distinguish different
patterns of drug use for diagnosis and treatment (see",
" \"Substance use disorders: Principles for recognition and assessment in
general medical care\"",
" </a>",
" ):",
" </p>",
" <p>",
" <li>",
" <strong>",
" Use",
" </strong>",
" — Sporadic consumption of alcohol or drugs with no adverse
consequences of that consumption.",
" </li>",
" <li>",
" <strong>",
" Abuse",
" </strong>",
" — Although the frequency of consumption of alcohol or drugs may vary,
some adverse consequences of that use are experienced by the user.",
" </li>",
" <li>",
" <strong>",
" Physical dependence",
" </strong>",
" — A state of adaptation that is manifested by a substance class-
specific withdrawal syndrome that can be produced by abrupt cessation or rapid dose
reduction of a substance, or by administration of an antagonist [",
" 5",
" </a>",
" ].",
" </li>",
" <li>",
" <strong>",
" Psychological dependence",
" </strong>",
" — A subjective sense of a need for a specific psychoactive substance,
either for its positive effects or to avoid negative effects associated with its
abstinence [",
" 5",
" </a>",
" ].",
" </li>",
" <li>",
" <strong>",
" Addiction",
" </strong>",
" — Addiction is a primary, chronic disease of brain reward, motivation,
memory and related circuitry [",
" 6",
" </a>",
" ]. Dysfunction in these circuits leads the individual to pathologically
pursue reward",
" and/or",
" </span>",
" relief by substance use and other behaviors. It is characterized by
inability to consistently abstain, impairment in behavioral control, craving,
diminished recognition of significant problems with one’s behaviors and
interpersonal relationships, and a dysfunctional emotional response. It often
involves cycles of relapse and remission.",
" </li>",
" </ul>",
" </p>",
" DRUG USE IN THE UNITED STATES",
" </span>",
" — Illicit drugs include",
" marijuana/hashish,",
" </span>",
" cocaine (including crack), heroin, hallucinogens, inhalants, and prescription
psychotherapeutics used non-medically. Results from the 2010 National Survey on
Drug Use and Health, which interviewed over 67,000 civilian noninstitutionalized
persons over age 12 years in the United States, revealed marijuana was the most
commonly used illicit drug, followed by (in decreasing order of frequency) non-
medical use of psychotherapeutics, cocaine, and hallucinogens [",
" 7",
" </a>",
" ]. In the non-medical use of psychotherapeutics group, the most commonly used
drugs were pain relievers, followed by tranquilizers, stimulants, and sedatives.",
" </p>",
" <p>",
" When interviewed, 4.4 percent of pregnant women stated that they had used
illicit substances in the past month, and a much larger proportion smoked
cigarettes or drank alcohol (",
" <a class=\"graphic graphic_table graphicRef62478 \" href=\"UTD.htm?
26/25/27036\">",
" table 1",
" </a>",
" ) [",
" 7",
" </a>",
" ]. The rates of illicit drug use among pregnant women by age group were: age
15 to 17 years (16.2 percent), age 18 to 25 years (7.4 percent), age 26
to 44 years (1.9 percent). Many women use more than one substance [",
" 2",
" </a>",
" ].",
" </p>",
" <p>",
" A retrospective serial, cross-sectional analysis of a nationally
representative sample of newborns with neonatal abstinence syndrome noted
antepartum maternal opiate use increased from 1.19 (95% CI 1.01-1.35) to 5.63 (95%
CI 4.40-6.71) per 1000 births per year from 2000 to 2009 accompanied by a
substantial increase in the incidence of neonatal abstinence syndrome, from 1.20
(95% CI 1.04-1.37) to 3.39 (95% CI 3.12-3.67) per 1000 hospital births per year [",
" 8",
" </a>",
" ].",
" </p>",
" SCREENING FOR DRUG USE",
" </span>",
" — The American College of Obstetricians and Gynecologists
(ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC)
consider screening for substance abuse a part of complete obstetric care and
recommend asking all pregnant women about their use of alcohol and illicit drugs
[",
" 9-11",
" </a>",
" ]. This recommendation is based on the prevalence of substance abuse in the
population, its adverse effects, and data from mostly nonrandomized studies that
intervention (education, prenatal care, treatment of substance abuse) can improve
some maternal and neonatal outcomes [",
" 12-18",
" </a>",
" ]. Screening followed by intervention can be cost effective [",
" 19",
" </a>",
" ].",
" </p>",
" <p>",
" Ideally, screening is performed at the initial prenatal visit [",
" 9",
" </a>",
" ], and repeat screening is performed periodically during pregnancy (eg, each
trimester). Substance users come from all socioeconomic strata, ages, and races [",
" 20,21",
" </a>",
" ], therefore, most users will only be identified if specifically asked about
the problem. In one report, a prenatal care system that did not routinely screen
for substance abuse identified less than one-third of women who subsequently had a
child removed from the home because of parental substance abuse [",
" 22",
" </a>",
" ].",
" </p>",
" <p>",
" Denial is a significant barrier to identifying these patients. Denial may
exist even when the patient is directly asked about drug use or confronted with
behaviors suspicious for use. Pregnant women may not admit to drug use because they
have guilt about its effect on their pregnancy, and fear legal consequences,
including involvement of child protection agencies and loss of custody of their
children [",
" 23",
" </a>",
" ]. Some states consider substance abuse during pregnancy to be child abuse and
a few consider it grounds for involuntary commitment to a treatment facility [",
" 24",
" </a>",
" ]. Providers should be aware of local laws and requirements, which vary
widely.",
" </p>",
" <p>",
" Objective screening (eg, urine testing) overcomes some of these barriers, but
is more costly and has other limitations. (See",
" 'Laboratory testing'",
" </a>",
" below.)",
" </p>",
" Screening tools",
" </span>",
" — Use of validated screening tools is recommended, but the
options are limited [",
" 9",
" </a>",
" ]. The 4P’s Plus Screen© for substance use in pregnancy consists of
questions about substance use by the patient (in the past or currently), her
parents, and her partner. An affirmative response should trigger further assessment
(see",
" 'Assessment of screen positive patients'",
" </a>",
" below). However, the 4P’s Plus Screen© is a copyrighted screening
instrument that may not be reproduced in any form without permission.",
" </p>",
" <p>",
" The CRAFFT Substance Abuse Screen for Adolescents and Young Adults is
available for use without restriction. It has had preliminary testing among
pregnant young adults and was found to be better than the medical record and the T-
ACE alcohol screen for identification of prenatal substance use [",
" 25",
" </a>",
" ]. Two or more positive responses to the following questions indicate the need
for further assessment:",
" </p>",
" <p>",
" <li>",
" <strong>",
" C",
" </strong>",
" - Have you ever ridden in a",
" <strong>",
" CAR",
" </strong>",
" driven by someone (including yourself) who was high or had been using
alcohol or drugs?",
" </li>",
" <li>",
" <strong>",
" R",
" </strong>",
" - Do you ever use alcohol or drugs to",
" <strong>",
" RELAX",
" </strong>",
" , feel better about yourself or fit in?",
" </li>",
" <li>",
" <strong>",
" A",
" </strong>",
" - Do you ever use alcohol or drugs while you are by yourself or",
" <strong>",
" ALONE",
" </strong>",
" ?",
" </li>",
" <li>",
" <strong>",
" F",
" </strong>",
" - Do you ever",
" <strong>",
" FORGET",
" </strong>",
" things you did while using alcohol or drugs?",
" </li>",
" <li>",
" <strong>",
" F",
" </strong>",
" - Do your",
" <strong>",
" FAMILY",
" </strong>",
" or",
" <strong>",
" friends",
" </strong>",
" ever tell you that you should cut down on your drinking or drug use?",
" </li>",
" <li>",
" <strong>",
" T",
" </strong>",
" - Have you ever gotten in",
" <strong>",
" TROUBLE",
" </strong>",
" while you were using alcohol or drugs?",
" </li>",
" </ul>",
" </p>",
" <p>",
" Screening tools are described in detail separately. (See",
" </a>",
" .)",
" </p>",
" Assessment of screen positive patients",
" </span>",
" — A practical, effective approach for interviewing women
about substance abuse is respectful and sensitive use of neutrally worded
questions. It is preferable to begin with questions about lawful substances, such
as cigarette smoking and alcohol, followed by questions about misuse of over-the-
counter drugs, such as",
" pseudoephedrine",
" </a>",
" products and",
" dextromethorphan",
" </a>",
" products, and then use of prescription drugs (opioid analgesics, sedatives,
stimulants, tranquilizers), and, finally, illegal substances (marijuana,
methamphetamine, cocaine, heroin, hallucinogens, and inhalants).",
" </p>",
" <p>",
" Ask about the frequency of drug use, length of the most recent pattern of use,
and time of last use. It may be helpful to ask about where, when, and with whom
drugs are most often used.",
" </p>",
" <p>",
" When appropriate, determine the route of administration: oral, intranasal,
subcutaneous injection (\"skin popping\"), or intravenous. If she has ever used a
needle to inject drugs, ask about shared needles.",
" </p>",
" <p>",
" For each substance, ask about the quantity used (ie, quantity of powder, unit
of sale from a dealer). Terms used for drug units vary regionally, and it is
helpful to be familiar with local drug slang and to ask for explanations of
unfamiliar terms. The amount of money spent on a",
" daily/weekly/monthly",
" </span>",
" basis for drugs may also be used to quantitate drug usage. However,
information about the quantity of drug use is not helpful in determining if an
individual has",
" abuse/dependence",
" </span>",
" and is not likely to be accurately reported.",
" </p>",
" <p>",
" Ask about participation in self-help programs such as Narcotics Anonymous
(NA), prior detoxification or addiction treatment, and abstinence periods. What has
been helpful in the past and what has been tried? How long was the longest period
of abstinence or maintenance treatment without using illicit drugs?",
" </p>",
" Risk factors for substance use",
" </span>",
" — The following characteristics may alert obstetrical
providers to an increased risk of substance abuse or dependence in women with
negative responses to direct questions about drug use [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6346/abstract/2,4,26-29\">",
" 2,4,26-29",
" </a>",
" ] (see",
" </a>",
" ):",
" </p>",
" <p>",
" <li>",
" Young woman (especially adolescents), unmarried women, and women with lower
educational achievement",
" </li>",
" <li>",
" Late initiation of prenatal care",
" </li>",
" <li>",
" Multiple missed prenatal visits",
" </li>",
" <li>",
" Impaired school or work performance",
" </li>",
" <li>",
" A sudden change in behavior, such as somnolence, intoxication, agitation,
aggression, disoriented or erratic behavior. Drug users may also exhibit symptoms
of depression, including loss of interest in eating, weight loss, and sleep
disturbance.",
" </li>",
" <li>",
" High-risk sexual behavior or history of sexually transmitted infections.
Women who are trading sex for drugs are at risk for these infections.",
" </li>",
" <li>",
" Relational problems, unstable home environment",
" </li>",
" <li>",
" Past obstetrical history of unexplained adverse events, such as miscarriage,
growth restriction, premature birth, abruptio placentae, stillbirth, or precipitous
delivery",
" </li>",
" <li>",
" Children not living with the mother or involved with child protection
agencies",
" </li>",
" <li>",
" History of medical problems associated with drug abuse (eg, cellulitis, skin
abscess, endocarditis, osteomyelitis, suspicious trauma, hepatitis, phlebitis,
tuberculosis), physical signs of drug use (eg, track marks, atrophy of the nasal
mucosa, erosion or perforation of the nasal septum), or physical signs of
withdrawal (dilation or constriction of pupils, tachycardia, conjunctival
injection, sweating, watery eyes, runny nose, slurred speech, yawning, unsteady
gait)",
" </li>",
" <li>",
" Poor dentition",
" </li>",
" <li>",
" Poor weight gain",
" </li>",
" <li>",
" Diagnosis of a mental health disorder",
" </li>",
" <li>",
" Family history of substance abuse",
" </li>",
" <li>",
" Encounters with law enforcement agencies because of violence or trauma,
theft, or prostitution",
" </li>",
" <li>",
" Having a partner who is a substance abuser. This is particularly important
in female patients who are often introduced to, and supplied with, drugs by a male
partner.",
" </li>",
" </ul>",
" </p>",
" Laboratory testing",
" </span>",
" — Universal laboratory testing for evidence of drug use is
not recommended because of the limitations of these tests [",
" 10",
" </a>",
" ]. The use and limitations of drug tests are described in detail separately.
(See",
general medical care\", section on 'Drug testing'",
" </a>",
" .)",
" </p>",
" <p>",
" There is no consensus among research groups regarding when drug tests should
be used in pregnant women or the best method for analyzing biological samples
(urine, blood, hair, saliva) [",
" 30",
" </a>",
" ]. Urine testing is most common. Possible clinical indications for laboratory
testing in pregnancy include:",
" </p>",
" <p>",
" <li>",
" Previous positive drug test",
" </li>",
" <li>",
" Monitoring compliance with",
" methadone",
" </a>",
" or",
" buprenorphine",
" </a>",
" use",
" </li>",
" <li>",
" Abruptio placenta",
" </li>",
" <li>",
" Idiopathic preterm labor",
" </li>",
" <li>",
" Idiopathic fetal growth restriction",
" </li>",
" <li>",
" Frequent requests for prescription drugs of abuse",
" </li>",
" <li>",
" Noncompliance with prenatal care",
" </li>",
" <li>",
" Unexplained fetal demise",
" </li>",
" </ul>",
" </p>",
" <p>",
" Positive tests for illicit drugs can have legal and economic implications.
Women should be informed of the potential ramifications of a positive test result
and should give informed consent prior to testing; random testing is unethical [",
" 31-33",
" </a>",
" ]. However, medically indicated drug testing without written consent is
acceptable in women who are unconscious or show obvious signs of intoxication and
need to be tested in order to provide the appropriate medical interventions.
Clinicians should be aware of their state's requirements for testing and reporting
drug test results.",
" </p>",
" GENERAL PRINCIPLES OF PRENATAL CARE OF THE SUBSTANCE USER",
" </span>",
" — Obstetrical providers should adhere to safe prescribing
practices of prescription drugs and encourage healthy behaviors. They should
educate patients about",
" maternal/fetal/neonatal",
" </span>",
" morbidity associated with substance use, identify substance users, and be
aware of local resources for consultation and patient referral [",
" 24",
" </a>",
" ].",
" </p>",
" <p>",
" Substance use assessment, counseling, and support by a nonjudgmental clinician
may motivate some women who use illicit drugs other than opioids to abstain. Most
others and all women dependent on opioids will require referral for in-depth
assessment followed by counseling and treatment. (See individual topics on specific
substances of abuse: marijuana, cocaine, amphetamines, non-medical use of
prescription medications, etc).",
" </p>",
" <p>",
" Few randomized trials have evaluated the optimum approach to management of
pregnant substance abusers [",
" 34-38",
" </a>",
" ]. Observational studies suggest that combining treatment of substance abuse
with comprehensive prenatal care can reduce the frequency of some maternal and
neonatal complications of maternal substance use [",
" 12-18",
" </a>",
" ]. Components of this care should be individualized based on patient-specific
factors, and may include the following [",
" <a class=\"abstract\" href=\"UTD.htm?6/12/6346/abstract/2,9,10,39\">",
" 2,9,10,39",
" </a>",
" ]:",
" </p>",
" <p>",
" <li>",
" Counsel about the risks associated with each drug the mother is using. Both
maternal and short- and long-term effects on offspring should be discussed.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" (See",
" 'Pregnancy complications associated with selected drugs'",
" </a>",
" below.)",
" </li>",
" <li>",
" (See",
" \"Cocaine abuse and dependence in adults\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Opioid abuse and dependence: Overview and patient evaluation\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Cannabis use disorders: Treatment, prognosis, and long-term medical
effects\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Methamphetamine abuse and dependence: Epidemiology, clinical
manifestations, course, assessment, and diagnosis\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Infants of mothers with substance abuse\"",
" </a>",
" .) ",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" Encourage the patient to moderate and, ideally, discontinue use of illicit
drugs; however, this depends on the specific drug and pattern of use.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" For women with opiate dependence, switching to",
" methadone",
" </a>",
" is preferable to detoxification, as it is safer and more successful.",
" Buprenorphine",
" </a>",
" is another option when opiate substitution therapy is under consideration
[",
" 40",
" </a>",
" ]. (See",
" \"Methadone maintenance therapy during pregnancy\"",
" </a>",
" .)",
" </li>",
" <li>",
" Women on high doses of benzodiazepines should undergo medical detoxification
to minimize or prevent withdrawal symptoms. (See",
" \"Benzodiazepine poisoning and withdrawal\", section on 'Withdrawal'",
" </a>",
" .)",
" </li>",
" <li>",
" If available, a program for management of discontinuation of cocaine or
marijuana may be useful. (See",
" \"Cocaine abuse and dependence in adults\", section on 'Treatment of
addiction'",
" </a>",
" and",
" \"Cannabis use disorders: Treatment, prognosis, and long-term medical
effects\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Prescription drug abuse and addiction: Prevention, identification, and
management\", section on 'Addressing misuse, abuse and addiction'",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" Identify comorbid conditions, such as psychiatric disorders and",
" physical/sexual/emotional",
" </span>",
" abuse, which occur frequently in substance abusers. The interrelationships
between these issues and substance use need to be addressed in caring for these
patients.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" (See",
" \"Intimate partner violence: Diagnosis and screening\"",
" </a>",
" and",
" \"Intimate partner violence: Intervention and patient management\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Depression in pregnant women: Clinical features and consequences\"",
" </a>",
" and",
" \"Bipolar disorder in women: Preconception and prenatal maintenance
pharmacotherapy\"",
" </a>",
" and",
" \"Bipolar disorder in pregnant women: Treatment of mania, hypomania, and
mixed episodes\"",
" </a>",
" and",
" \"Bipolar disorder in pregnant women: Treatment of major depression\"",
" </a>",
" and",
" \"Obsessive-compulsive disorder in pregnant and postpartum women\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" Assemble a multidisciplinary team to comprehensively assess and participate
in the care of these women and their offspring. The team may include obstetrical,
medical, pediatric, psychiatric, addiction medicine, and social service
providers.",
" </li>",
" <li>",
" Address the needs of poorly nourished, homeless,",
" and/or",
" </span>",
" incarcerated pregnant substance abusers. In addition to education about
nutrition and weight gain, some of these women may need referral to food assistance
programs and shelters, and provision of transportation vouchers and prenatal
multivitamins.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" (See",
" \"Pregnancy in homeless women\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Prenatal care for incarcerated women\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Weight gain and loss in pregnancy\"",
" </a>",
" and",
" \"Nutrition in pregnancy\"",
" </a>",
" .)",
" <br/>",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" Test for sexually transmitted diseases (eg, syphilis, gonorrhea, chlamydia,
hepatitis B and C, human immunodeficiency virus) and tuberculosis, which may be
transmitted to the fetus or neonate. These tests should be repeated in the third
trimester in women who remain at increased risk.",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" (See",
" \"Initial prenatal assessment and patient education\"",
" </a>",
" and",
" \"Prenatal care (after initial prenatal assessment)\", section on 'Sexually
transmitted disease'",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Syphilis in pregnancy\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Prenatal evaluation and intrapartum management of the HIV-infected
patient in resource-rich settings\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Vertical transmission of hepatitis C virus\"",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Epidemiology, transmission, and prevention of hepatitis B virus
infection\", section on 'Perinatal transmission'",
" </a>",
" .)",
" </li>",
" <li>",
" (See",
" \"Tuberculosis in pregnancy\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p>",
" <li>",
" During prenatal visits, provide education and support, monitor maternal and
fetal status, and assess for complications of pregnancy or health problems related
to addiction.",
" </li>",
" <li>",
" Obtain an early ultrasound examination to provide the most accurate
determination of gestational age, which is important for later evaluation of fetal
growth and accurate diagnosis of preterm versus term or postterm gestation. (See",
" \"Prenatal assessment of gestational age\"",
" </a>",
" .)",
" </li>",
" <li>",
" Assess for fetal growth restriction in the second half of pregnancy. (See",
" \"Fetal growth restriction: Evaluation and management\"",
" </a>",
" .)",
" </li>",
" <li>",
" Perform antepartum fetal surveillance for standard obstetrical indications
(eg, growth restriction, antepartum bleeding, preeclampsia) or maternal withdrawal.
Substance use alone is not an indication for fetal monitoring with nonstress tests
or the biophysical profile. (See",
" \"Overview of fetal assessment\"",
" </a>",
" .)",
" </li>",
" <li>",
" Consult the anesthesia service prior to delivery to develop a pain
management plan [",
" 41,42",
" </a>",
" ]. Women with substance abuse disorders, especially those involving opioids,
may be more sensitive to pain, may not obtain adequate pain relief with usual doses
of pain relievers, and may have difficult venous access [",
" 43,44",
" </a>",
" ].",
" </li>",
" <li>",
" Inform the pediatric service of the possibility of neonatal withdrawal.
(See",
" \"Neonatal opioid withdrawal (Neonatal abstinence syndrome)\"",
" </a>",
" .)",
" </li>",
" <li>",
" Discuss the risks and benefits of breastfeeding. Women who use illicit drugs
should understand that these drugs can be detected in breast milk and can affect
the neonate. (See",
" \"Infants of mothers with substance abuse\", section on 'Breastfeeding'",
" </a>",
" .) Women on",
" methadone",
" </a>",
" or",
" buprenorphine",
" </a>",
" may be encouraged to breastfeed; however, caution should be exercised if
mothers are abusing other illicit substances",
" and/or",
" </span>",
" being treated with multiple prescription drugs. (See",
" \"Methadone maintenance therapy during pregnancy\", section on
'Breastfeeding'",
" </a>",
" .) The American Academy of Pediatrics (AAP) generally recommends against
breastfeeding for women on amphetamines [",
" 45",
" </a>",
" ].",
" </li>",
" </ul>",
" </p>",
" PREGNANCY COMPLICATIONS ASSOCIATED WITH SELECTED DRUGS",
" </span>",
" — The effect of any illicit drug on pregnancy outcome is
difficult to ascertain because data are scarce and confounded by the influence of
other factors, including polysubstance use, poor nutrition, poverty, co-morbid
disorders, and inadequate prenatal care. In addition, reliable ascertainment of the
extent of drug use during pregnancy and drug",
" dose/purity",
" </span>",
" are impossible.",
" </p>",
" <p>",
" The clinical manifestations of drug abuse are diverse, and differ by drug and
setting (eg, usual dose, overdose, withdrawal). Combined with the physiologic
changes of pregnancy and the clinical manifestations of coexisting pregnancy-
related disease, diagnosis of patients presenting with serious clinical
abnormalities can be challenging. For example, cocaine, heroin, and amphetamine
overdose can cause hypertension and seizures, similar to",
" preeclampsia/eclampsia.",
" </span>",
" </p>",
" Opiates",
" </span>",
" — Many of the medical risks associated with heroin addiction
are the same for both pregnant and nonpregnant women, and similar for addiction to
other opiates. In addition, opiate users typically have financial, social, and
psychological problems that cause psychosocial stress, expose them to violence [",
" 46",
" </a>",
" ], and affect their options and treatment [",
" 2",
" </a>",
" ]. (See",
" \"Opioid abuse and dependence: Overview and patient evaluation\"",
" </a>",
" and",
" \"Treatment of opioid abuse and dependence\"",
" </a>",
" .)",
" </p>",
" <p>",
" Multiple obstetrical complications have been associated with opiate-dependence
in pregnancy [",
" 47",
" </a>",
" ]. However, it is difficult to establish the extent to which these problems
are due to opiates or opiate withdrawal or other drugs used by polydrug abusers
versus coexistent maternal medical, nutritional, psychological, and socioeconomic
issues.",
" </p>",
" <p>",
" <li>",
" Abruptio placentae",
" </li>",
" <li>",
" Fetal death",
" </li>",
" <li>",
" Intraamniotic infection",
" </li>",
" <li>",
" Fetal growth restriction",
" </li>",
" <li>",
" Fetal passage of meconium",
" </li>",
" <li>",
" Preeclampsia",
" </li>",
" <li>",
" Premature labor and delivery",
" </li>",
" <li>",
" Premature rupture of membranes",
" </li>",
" <li>",
" Placental insufficiency",
" </li>",
" <li>",
" Miscarriage",
" </li>",
" <li>",
" Postpartum hemorrhage",
" </li>",
" <li>",
" Septic thrombophlebitis",
" </li>",
" </ul>",
" </p>",
" <p>",
" Neonatal outcomes, including neonatal abstinence syndrome, are reviewed
separately. (See",
" \"Infants of mothers with substance abuse\", section on 'Opioids'",
" </a>",
" and",
" </a>",
" .)",
" </p>",
" Opioid-substitution therapy",
" </span>",
" — For opioid-dependent women, opioid substitution therapy
with",
" methadone",
" </a>",
" or",
" buprenorphine",
" </a>",
" offers overwhelming advantages compared to continued use of heroin (eg, oral
administration, known dose and purity, safe and steady availability, improved",
" maternal/fetal/neonatal",
" </span>",
" outcomes). In addition, it offers a unique opportunity to bring women into
medical and obstetrical care systems. Substitution therapy is preferable to
medication-assisted withdrawal (detoxification) because it is safe and associated
with a lower rate of resumption of heroin use [",
" 48,49",
" </a>",
" ]. Clinical use of methadone and buprenorphine in pregnant women, as well as",
" fetal/neonatal",
" </span>",
" effects, are discussed in detail separately. (See",
" \"Methadone maintenance therapy during pregnancy\"",
" </a>",
" and",
" </a>",
" and",
" \"Infants of mothers with substance abuse\"",
" </a>",
" .)",
" </p>",
" Marijuana",
" </span>",
" — Marijuana is the most common illicit substance used during
pregnancy. Prevalence varies according to maternal age, racial or ethnic
background, and socioeconomic status. (See",
" \"Cannabis use disorders: Epidemiology, comorbidity, and pathogenesis\"",
" </a>",
" .) For women under 21, however, alcohol is an ‘illicit’ substance
and is more commonly used than marijuana. (See",
" \"Alcohol intake and pregnancy\"",
" </a>",
" .) ",
" </p>",
" <p>",
" The impact of prenatal marijuana use on pregnancy outcome is not clear.
Adverse effects have not been consistently reported and there is no strong evidence
of an increase in congenital anomalies or growth restriction [",
" 50-52",
" </a>",
" ]. The findings from available studies are limited by relatively small numbers
of subjects whose substance use was limited to cannabis alone.",
" </p>",
" <p>",
" Observational studies have not reported an association between marijuana use
and preterm birth [",
" 51,52",
" </a>",
" ]. This finding is supported by an in vitro study in which human myometrial
biopsy specimens obtained at elective term cesarean delivery were exposed to
endogenous and exogenous cannabinoids [",
" 53",
" </a>",
" ]. Both endogenous and exogenous cannabinoids relaxed uterine muscle, a
response mediated through the cannabinoid receptor, CB1. Although this study
supports the observation that use of marijuana is not associated with preterm
birth, it does not address possible central, fetal, or placental effects of the
drug. The cannabinoid receptor may also play a role in tubal transport and ectopic
pregnancy [",
" 54,55",
" </a>",
" ].",
" </p>",
" <p>",
" Short and long-term effects of maternal marijuana use on offspring are
reviewed separately. (See",
" \"Infants of mothers with substance abuse\", section on 'Marijuana'",
" </a>",
" .)",
" </p>",
" Cocaine",
" </span>",
" — Public and professional interest in prenatal cocaine use is
high, although many more pregnant women smoke cigarettes, drink alcohol, or smoke
marijuana than use cocaine [",
" 56-61",
" </a>",
" ]. Female",
" crack/cocaine",
" </span>",
" users in their thirties constitute a fast growing group of new users who do
not use other substances. (See",
" </a>",
" .)",
" </p>",
" <p>",
" Cocaine readily crosses the placenta and fetal blood-brain barrier;
vasoconstriction is the major purported mechanism for fetal and placental damage
[",
" 62",
" </a>",
" ]. The putative consequences of prenatal cocaine exposure have been described
in hundreds of articles. The applicability of any of the studies is limited by
methodologic shortcomings, such as failure to control for maternal age, parity,
socioeconomic factors, and exposure to other drugs, alcohol, and cigarettes.",
" </p>",
" <p>",
" The few adequately controlled reports suggest that cocaine's effects are
related to dose and stage of pregnancy. A meta-analysis including 31 studies that
evaluated the relationship between maternal antenatal cocaine exposure and five
adverse perinatal outcomes found cocaine use during pregnancy significantly
increased the risks of [",
" 63",
" </a>",
" ]:",
" </p>",
" <p>",
" <li>",
" Preterm birth (OR 3.38, 95% CI 2.72-4.21)",
" </li>",
" <li>",
" Low birthweight (OR 3.66, 95% CI 2.90-4.63)",
" </li>",
" <li>",
" Small for gestational age infant (OR 3.23, 95% CI 2.43-4.30)",
" </li>",
" <li>",
" Shorter gestational age at delivery (-1.47 week, 95% CI -1.97 to -0.98)",
" </li>",
" <li>",
" Reduced birthweight (-492 grams, 95% CI -562 to -421 grams)",
" </li>",
" </ul>",
" </p>",
" <p>",
" Others have reported increased risks of miscarriage, abruptio placentae, and
decreased length (-0.71 cm) and head circumference (-0.43 cm) at birth [",
" 64-66",
" </a>",
" ]. Teratogenic effects have not been definitively proven. (See",
" \"Infants of mothers with substance abuse\", section on 'Cocaine'",
" </a>",
" .)",
" </p>",
" <p>",
" Cardiovascular cocaine toxicity is increased in pregnant women [",
" 62",
" </a>",
" ]. Cocaine toxicity usually causes hypertension, which may mimic preeclampsia.
Beta-adrenergic antagonists (ie, beta blockers) should be avoided in the treatment
of cocaine-related cardiovascular complications because they create unopposed
alpha-adrenergic stimulation and are associated with coronary vasoconstriction and
end-organ ischemia. This contraindication includes",
" labetalol",
" </a>",
" , which has predominantly beta-blocking effects.",
" Hydralazine",
" </a>",
" is preferred for treatment of hypertension in pregnant cocaine users [",
" 67",
" </a>",
" ]. Decisions regarding the administration of peripartum analgesia or
anesthesia need to be individualized, taking into account factors such as the
combined effects of cocaine, analgesia, and anesthesia on the patient's
cardiovascular and hematological status [",
" 68",
" </a>",
" ]. (See",
" \"Cocaine: Acute intoxication\"",
" </a>",
" and",
" </a>",
" and",
" \"Evaluation and management of the cardiovascular complications of cocaine
abuse\"",
" </a>",
" .)",
" </p>",
" Amphetamines including methamphetamine",
" </span>",
" — A diagnosis of amphetamine abuse is becoming more common
among women of reproductive age, including hospitalized pregnant women [",
" 69-72",
" </a>",
" ]. Methamphetamine, commonly known as speed, meth, and chalk, or as ice,
crystal, and glass when smoked, is a powerfully addictive stimulant. It is the drug
most often produced by clandestine laboratories in the United States. About 10
million people have tried methamphetamine at some point in their lives, with abuse
spreading eastward from its historic base in the west and southwest [",
" 73",
" </a>",
" ]. It is a known neurotoxic agent, which damages the endings of brain cells
containing dopamine.",
" </p>",
" <p>",
" Amphetamines and their byproducts cross the placenta [",
" 74",
" </a>",
" ]. Definitive information on the impact of exposure to methamphetamine in
utero is lacking; most studies have focused on prenatal methamphetamine exposure in
animal models. Amphetamines can cause hypertension and headache, suggestive of
preeclampsia. Sheep studies have demonstrated that maternal administration of
methamphetamine has cardiovascular and metabolic effects on the fetus (eg, increase
in blood pressure, decrease in PO",
" <sub>",
" 2",
" </sub>",
" and pH) [",
" 75-77",
" </a>",
" ].",
" </p>",
" <p>",
" No fetal structural abnormality has been definitively associated with
perinatal amphetamine exposure [",
" 78",
" </a>",
" ].",
" </p>",
" <p>",
" Although studies consistently report that amphetamine exposure during
pregnancy is associated with an increased risk of preterm birth, low birthweight,
and birth of small for gestational age infants when compared with the general
obstetric population, most of these studies have not adjusted for confounding
factors, such as tobacco use, polydrug exposure, nutrition, and access to prenatal
care [",
" 79",
" </a>",
" ]. However, a multivariate analysis that controlled for gender, maternal
socioeconomic status, level of prenatal care, maternal marital status, maternal age
and weight gain, and prenatal alcohol, tobacco, marijuana exposure, found that
infants with prenatal methamphetamine exposure had a two-fold increased risk for
intrauterine growth restriction compared to infants not exposed to methamphetamine
[",
" 80",
" </a>",
" ].",
" </p>",
" <p>",
" The Infant Development, Environment and Lifestyle study, which compared
outcomes of 84 methamphetamine exposed and 1534 unexposed subjects, also reported
growth restriction in exposed fetuses [",
" 81,82",
" </a>",
" ]. Methamphetamine exposure was determined by maternal self-report",
" and/or",
" </span>",
" gas chromatography-mass spectrometry confirmation of amphetamine and
metabolites in infant meconium; unexposed mothers denied amphetamine use and their
infants had a negative meconium screen. Mothers in both groups used prenatal
alcohol, tobacco, or marijuana; mothers who used opiates, lysergic acid
diethylamide (LSD), phencyclidine (PCP), or cocaine were excluded. The
methamphetamine exposed group was 3.5 times more likely to be small for gestational
age than the unexposed group.",
" </p>",
" <p>",
" Short-term neonatal effects and long-term outcomes in offspring are reviewed
separately. (See",
" \"Infants of mothers with substance abuse\", section on 'Amphetamines'",
" </a>",
" .)",
" </p>",
" RESOURCES",
" </span>",
" </p>",
" <p>",
" <li>",
" <a class=\"external\" href=\"file://www.asam.org/\">",
" American Society of Addiction Medicine",
" </a>",
" </li>",
" <li>",
" <a class=\"external\" href=\"file://www.samhsa.gov/\">",
" Substance Abuse and Mental Health Services Administration",
" </a>",
" </li>",
" <li>",
" <a class=\"external\" href=\"file://www.acog.org/\">",
" American College of Obstetrics and Gynecology",
" </a>",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"PATIENT_INFORMATION\">",
" </span>",
" — UpToDate offers two types of patient education materials,
“The Basics” and “Beyond the Basics.” The Basics patient
education pieces are written in plain language, at the 5",
" <sup>",
" th",
" </sup>",
" to 6",
" <sup>",
" th",
" </sup>",
" grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10",
" <sup>",
" th",
" </sup>",
" to 12",
" <sup>",
" th",
" </sup>",
" grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.",
" </p>",
" <p>",
" Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)",
" </p>",
" <p>",
" <li>",
" Basics topics (see",
" \"Patient information: Alcohol and illegal drug use in pregnancy (The
Basics)\"",
" </a>",
" )",
" </li>",
" </ul>",
" </p>",
" </span>",
" </p>",
" <p>",
" <li>",
" Identification and treatment of women who use illicit drugs can decrease
maternal drug use during pregnancy. Given the potential adverse fetal and maternal
effects of drug use, we recommend screening all pregnant women for drug use (",
" Grade 1C",
" </a>",
" ). (See",
" 'Introduction'",
" </a>",
" above and",
" 'Screening for drug use'",
" </a>",
" above.)",
" </li>",
" <li>",
" The most practical screening method is to ask specific questions about drug
use using a screening tool. Pregnant women may not admit drug use because of guilt
about its effect on their pregnancy, and fear legal consequences, including loss of
custody of children. (See",
" 'Screening for drug use'",
" </a>",
" above and",
" 'Screening tools'",
" </a>",
" above.)",
" </li>",
" <li>",
" Risk factors for increased likelihood of substance abuse include late
initiation of prenatal care, multiple missed prenatal visits, past adverse
obstetrical history, children with neurodevelopmental or behavioral problems,
children not living with the mother, history of drug or alcohol mediated medical
problems, substance abuse in a partner or family member, and frequent encounters
with law enforcement agencies. (See",
" 'Risk factors for substance use'",
" </a>",
" above.) Universal laboratory testing for evidence of drug use is not
recommended because of the limitations of these tests. Possible clinical
indications for laboratory testing after informed consent in selected pregnant
women include: previous positive drug test, monitoring compliance with",
" methadone",
" </a>",
" or",
" buprenorphine",
" </a>",
" use, unexplained abruptio placenta or fetal demise. Clinicians should be
aware of their state’s requirements for testing and reporting drug test
results. (See",
" 'Laboratory testing'",
" </a>",
" above.)",
" </li>",
" <li>",
" Few randomized trials have evaluated the optimum approach to management of
pregnant substance abusers. Observational studies suggest that combining treatment
of substance abuse with comprehensive prenatal care can reduce the frequency of
some maternal and neonatal complications of maternal substance use. Components of
this care should be individualized based on patient-specific factors. (See",
" 'General principles of prenatal care of the substance user'",
" </a>",
" above.)",
" </li>",
" <li>",
" For women dependent on opiates, we suggest opiate substitution treatment
rather than medical detoxification or no treatment (",
" Grade 2C",
" </a>",
" ).",
" Methadone",
" </a>",
" or",
" buprenorphine",
" </a>",
" may be used; neither drug is clearly superior, but there is more experience
with methadone. Methadone use is associated with fewer",
" fetal/neonatal",
" </span>",
" complications and side effects than detoxification or continued use of un-
prescribed opiates. (See",
" 'Opioid-substitution therapy'",
" </a>",
" above.)",
" </li>",
" <li>",
" Cocaine can cause vasoconstriction of uterine vessels, which is the probable
major mechanism for fetal and placental injury leading to abruptio placentae,
spontaneous abortion, prematurity, and fetal death. (See",
" 'Cocaine'",
" </a>",
" above.)",
" </li>",
" <li>",
" There is no high quality evidence showing an adverse effect of marijuana on
pregnancy outcome, but data are limited. (See",
" 'Marijuana'",
" </a>",
" above.)",
" </li>",
" <li>",
" Definitive information on the impact of exposure to methamphetamine in utero
is not available. (See",
" 'Amphetamines including methamphetamine'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
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" Gouin K, Murphy K, Shah PS, Knowledge Synthesis group on Determinants of Low
Birth Weight and Preterm Births. Effects of cocaine use during pregnancy on low
birthweight and preterm birth: systematic review and metaanalyses. Am J Obstet
Gynecol 2011; 204:340.e1.",
" </a>",
" </li>",
" <li>",
" Bada HS, Das A, Bauer CR, et al. Gestational cocaine exposure and
intrauterine growth: maternal lifestyle study. Obstet Gynecol 2002; 100:916.",
" </a>",
" </li>",
" <li>",
" Richardson GA, Hamel SC, Goldschmidt L, Day NL. Growth of infants prenatally
exposed to cocaine/crack: comparison of a prenatal care and a no prenatal care
sample. Pediatrics 1999; 104:e18.",
" </a>",
" </li>",
" <li>",
" Bandstra ES, Morrow CE, Anthony JC, et al. Intrauterine growth of full-term
infants: impact of prenatal cocaine exposure. Pediatrics 2001; 108:1309.",
" </a>",
" </li>",
" <li>",
" Krzysztof, M. Current opinion in obstetrics and gynecology 2007; 19:578.",
" </a>",
" </li>",
" <li>",
" Kuczkowski KM. The cocaine abusing parturient: a review of anesthetic
considerations. Can J Anaesth 2004; 51:145.",
" </a>",
" </li>",
" <li>",
" Cox S, Posner SF, Kourtis AP, Jamieson DJ. Hospitalizations with amphetamine
abuse among pregnant women. Obstet Gynecol 2008; 111:341.",
" </a>",
" </li>",
" <li>",
" Terplan M, Smith EJ, Kozloski MJ, Pollack HA. Methamphetamine use among
pregnant women. Obstet Gynecol 2009; 113:1285.",
" </a>",
" </li>",
" <li>",
" American College of Obstetricians and Gynecologists Committee on Health Care
for Underserved Women. Committee Opinion No. 479: Methamphetamine abuse in women of
reproductive age. Obstet Gynecol 2011; 117:751.",
" </a>",
" </li>",
" <li>",
" Oei JL, Kingsbury A, Dhawan A, et al. Amphetamines, the pregnant woman and
her children: a review. J Perinatol 2012; 32:737.",
" </a>",
" </li>",
" <li>",
" file://www.nida.nih.gov/ResearchReports/methamph/methamph.html. (Accessed May
24, 2010).",
" </li>",
" <li>",
" Jones J, Rios R, Jones M, et al. Determination of amphetamine and
methamphetamine in umbilical cord using liquid chromatography-tandem mass
spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2009; 877:3701.",
" </a>",
" </li>",
" <li>",
" Stek AM, Baker RS, Fisher BK, et al. Fetal responses to maternal and fetal
methamphetamine administration in sheep. Am J Obstet Gynecol 1995; 173:1592.",
" </a>",
" </li>",
" <li>",
" Dickinson JE, Andres RL, Parisi VM. The ovine fetal sympathoadrenal response
to the maternal administration of methamphetamine. Am J Obstet Gynecol 1994;
170:1452.",
" </a>",
" </li>",
" <li>",
" Stek AM, Fisher BK, Baker RS, et al. Maternal and fetal cardiovascular
responses to methamphetamine in the pregnant sheep. Am J Obstet Gynecol 1993;
169:888.",
" </a>",
" </li>",
" <li>",
" Oei JL, Kingsbury A, Dhawan A, et al. Amphetamines, the pregnant woman and
her children: a review. J Perinatol 2012; 32:737.",
" </a>",
" </li>",
" <li>",
" Ladhani NN, Shah PS, Murphy KE, Knowledge Synthesis Group on Determinants of
Preterm/LBW Births. Prenatal amphetamine exposure and birth outcomes: a systematic
review and metaanalysis. Am J Obstet Gynecol 2011; 205:219.e1.",
" </a>",
" </li>",
" <li>",
" Nguyen D, Smith LM, Lagasse LL, et al. Intrauterine growth of infants
exposed to prenatal methamphetamine: results from the infant development,
environment, and lifestyle study. J Pediatr 2010; 157:337.",
" </a>",
" </li>",
" <li>",
" Arria AM, Derauf C, Lagasse LL, et al. Methamphetamine and other substance
use during pregnancy: preliminary estimates from the Infant Development,
Environment, and Lifestyle (IDEAL) study. Matern Child Health J 2006; 10:293.",
" </a>",
" </li>",
" <li>",
" Smith LM, LaGasse LL, Derauf C, et al. The infant development, environment,
and lifestyle study: effects of prenatal methamphetamine exposure, polydrug
exposure, and poverty on intrauterine growth. Pediatrics 2006; 118:1149.",
" </a>",
" </li>",
" </ol>",
" </div>",
" </div>",
" </div>",
" </span>",
" |",
" </span>",
" </a>",
" |",
" </span>",
" Release: 21.6- C21.56",
" </span>",
" <br/>",
" Licensed to:",
" </span>",
" </span>",
" |",
" </span>",
" Support Tag: [0503-122.72.76.133-F708DC0240-S244013.14]",
" <br/>",
" </span>",
" </div>",
" </div>",
"</div>"].join("\n");
" </a>",
" </div>",
" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <ul>",
" <li>",
" <a class=\"sr_button\" href=\"#H22\" id=\"summRecButton\">",
" <span>",
" SUMMARY & RECOMMENDATIONS",
" </span>",
" </a>",
" </li>",
" INTRODUCTION",
" </a>",
" </li>",
" DEFINITIONS",
" </a>",
" </li>",
" DRUG USE IN THE UNITED STATES",
" </a>",
" </li>",
" SCREENING FOR DRUG USE",
" </a>",
" </li>",
" Screening tools",
" </a>",
" </li>",
" Assessment of screen positive patients",
" </a>",
" </li>",
" Risk factors for substance use",
" </a>",
" </li>",
" Laboratory testing",
" </a>",
" </li>",
" GENERAL PRINCIPLES OF PRENATAL CARE OF THE SUBSTANCE USER",
" </a>",
" </li>",
" PREGNANCY COMPLICATIONS ASSOCIATED WITH SELECTED DRUGS",
" </a>",
" </li>",
" Opiates",
" </a>",
" </li>",
" - Opioid-substitution therapy",
" </a>",
" </li>",
" Marijuana",
" </a>",
" </li>",
" Cocaine",
" </a>",
" </li>",
" Amphetamines including methamphetamine",
" </a>",
" </li>",
" RESOURCES",
" </a>",
" </li>",
" <a class=\"outlineLink\" href=\"#PATIENT_INFORMATION\">",
" </a>",
" </li>",
" </a>",
" </li>",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" <div class=\"openRelatedGraphics\" id=\"OBGYN/4799\" rel=\"outline_link\">",
" GRAPHICS",
" <a class=\"graphics_icon\" href=\"#\" title=\"View All Related Graphics\">",
" View All",
" </a>",
" </div>",
" </h1>",
" <div id=\"relatedGraphics\">",
" <ul>",
" <div class=\"openRelatedGraphics\" id=\"OBGYN/4799|TAB\">",
" <a href=\"#\" title=\"TABLES\">",
" TABLES",
" </a>",
" </div>",
" </li>",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?26/25/27036\" title=\"table
1\">",
" Prevalence of substance abuse in pregnancy",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <ul>",
" Alcohol intake and pregnancy",
" </a>",
" </li>",
" Benzodiazepine poisoning and withdrawal",
" </a>",
" </li>",
" Bipolar disorder in pregnant women: Treatment of major depression",
" </a>",
" </li>",
" Bipolar disorder in pregnant women: Treatment of mania, hypomania, and mixed
episodes",
" </a>",
" </li>",
" Bipolar disorder in women: Preconception and prenatal maintenance
pharmacotherapy",
" </a>",
" </li>",
" Cannabis use disorders: Epidemiology, comorbidity, and pathogenesis",
" </a>",
" </li>",
" Cannabis use disorders: Treatment, prognosis, and long-term medical
effects",
" </a>",
" </li>",
" Cocaine abuse and dependence in adults",
" </a>",
" </li>",
" Cocaine: Acute intoxication",
" </a>",
" </li>",
" Depression in pregnant women: Clinical features and consequences",
" </a>",
" </li>",
" Epidemiology, transmission, and prevention of hepatitis B virus infection",
" </a>",
" </li>",
" Evaluation and management of the cardiovascular complications of cocaine
abuse",
" </a>",
" </li>",
" Fetal growth restriction: Evaluation and management",
" </a>",
" </li>",
" Infants of mothers with substance abuse",
" </a>",
" </li>",
" Initial prenatal assessment and patient education",
" </a>",
" </li>",
" Intimate partner violence: Diagnosis and screening",
" </a>",
" </li>",
" Intimate partner violence: Intervention and patient management",
" </a>",
" </li>",
" Methadone maintenance therapy during pregnancy",
" </a>",
" </li>",
" Methamphetamine abuse and dependence: Epidemiology, clinical manifestations,
course, assessment, and diagnosis",
" </a>",
" </li>",
" Neonatal opioid withdrawal (Neonatal abstinence syndrome)",
" </a>",
" </li>",
" Nutrition in pregnancy",
" </a>",
" </li>",
" Obsessive-compulsive disorder in pregnant and postpartum women",
" </a>",
" </li>",
" Opioid abuse and dependence: Overview and patient evaluation",
" </a>",
" </li>",
" Overview of fetal assessment",
" </a>",
" </li>",
" Patient information: Alcohol and illegal drug use in pregnancy (The
Basics)",
" </a>",
" </li>",
" Pregnancy in homeless women",
" </a>",
" </li>",
" Prenatal assessment of gestational age",
" </a>",
" </li>",
" Prenatal care (after initial prenatal assessment)",
" </a>",
" </li>",
" Prenatal care for incarcerated women",
" </a>",
" </li>",
" Prenatal evaluation and intrapartum management of the HIV-infected patient
in resource-rich settings",
" </a>",
" </li>",
" Prescription drug abuse and addiction: Prevention, identification, and
management",
" </a>",
" </li>",
" Substance use disorders: Principles for recognition and assessment in
general medical care",
" </a>",
" </li>",
" Syphilis in pregnancy",
" </a>",
" </li>",
" Treatment of opioid abuse and dependence",
" </a>",
" </li>",
" Tuberculosis in pregnancy",
" </a>",
" </li>",
" Vertical transmission of hepatitis C virus",
" </a>",
" </li>",
" Weight gain and loss in pregnancy",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>"].join("\n");
var title_f6_12_6347="Hemodynamics kidney pregnancy";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=NEPH
%2F66445&source=image_view&view=print&elapsedTimeMs=11\"
onclick=\"\">",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=NEPH
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"figure\">",
" Hemodynamic and renal changes during normal pregnancy",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Systemic hemodynamics",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Increase in cardiac output",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Fall in vascular resistance and blood pressure",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Blood volume expansion",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle1_single\">",
" Renal function and electrolyte balance",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Increase in glomerular filtration rate",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Chronic respiratory alkalosis",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Hyponatremia due to resetting of osmostat",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Increased ADH metabolism and polyuria in selected women",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" </div>",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6348="Visual behavior infants";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=PEDS
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=PEDS
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" Normal visual behavior of infants",
" </div>",
" <tbody>",
" <tr>",
" <td class=\"subtitle1\">",
" Age, months",
" </td>",
" Behavior",
" </td>",
" </tr>",
" <tr>",
" <td rowspan=\"3\">",
" 0 to 1",
" </td>",
" <td>",
" Turns eyes and head to look at light sources",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Horizontal tracking",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Eye contact at 6 to 8 weeks",
" </td>",
" </tr>",
" <tr class=\"divider_top\">",
" 2 to 3",
" </td>",
" <td>",
" Intense eye contact",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Vertical and circular tracking",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Interested in mobiles",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Interested in \"lip reading\"",
" </td>",
" </tr>",
" 3 to 6",
" </td>",
" <td>",
" Watches own hands",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Reaches toward, later grasps, hanging objects",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Observes toys falling and rolling away",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Shifts fixation across midline",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Visual sphere of attention widens gradually",
" </td>",
" </tr>",
" 7 to 10",
" </td>",
" <td>",
" Notices small bread crumbs",
" </td>",
" </tr>",
" <tr>",
" <td>",
" First touches them, then develops pincer grasp",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Interested in pictures",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Recognizes partially hidden objects",
" </td>",
" </tr>",
" 11 to 12",
" </td>",
" <td>",
" Visual orientation at home",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Looks through window and recognizes people, recognizes pictures, plays
hide-and-seek",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" </div>",
" Reproduced with permission from: Hyvarinen L. Assessment of visually impaired
infants. Ophthalmol Clin North Am 1994; 7:219. Copyright © 1994 WB Saunders.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6349="Psychiatric DXs in fibromyalgia";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=RHEUM
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=RHEUM
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" Percentage of fibromyalgia (FM) patients, FM nonpatients, and healthy controls
with lifetime psychiatric diagnoses",
" </div>",
" <tbody>",
" <tr>",
" Diagnosis",
" </td>",
" FM Patients n=64",
" </td>",
" FM Nonpatients n=28",
" </td>",
" Healthy controls n-23",
" </td>",
" P",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist1_start\">",
" Anxiety disorders",
" </td>",
" <td class=\"sublist_other_start\">",
" 60",
" </td>",
" 36",
" </td>",
" 26",
" </td>",
" 0.008*",
" </td>",
" </tr>",
" <tr>",
" <td class=\"sublist1\">",
" Simple phobia",
" </td>",
" <td class=\"sublist_other\">",
" 38",
" </td>",
" 18",
" </td>",
" 4",
" </td>",
" 0.001",
" </td>",
" </tr>",
" <tr>",
" Panic disorder with agoraphobia",
" </td>",
" 11",
" </td>",
" 0",
" </td>",
" 0",
" </td>",
" 0.050",
" </td>",
" </tr>",
" <tr>",
" Mood disorders",
" </td>",
" 52",
" </td>",
" 18",
" </td>",
" 22",
" </td>",
" 0.002*",
" </td>",
" </tr>",
" <tr>",
" Major depressive episode",
" </td>",
" 39",
" </td>",
" 11",
" </td>",
" 9",
" </td>",
" 0.001",
" </td>",
" </tr>",
" <tr>",
" Major depression-recurrent episode",
" </td>",
" 25",
" </td>",
" 7",
" </td>",
" 4",
" </td>",
" 0.014",
" </td>",
" </tr>",
" <tr>",
" Dysthymic disorder",
" </td>",
" 22",
" </td>",
" 7",
" </td>",
" 0",
" </td>",
" 0.004",
" </td>",
" </tr>",
" <tr>",
" Bipolar disorder",
" </td>",
" 13",
" </td>",
" 4",
" </td>",
" 0",
" </td>",
" 0.043",
" </td>",
" </tr>",
" <tr>",
" Body image disorders",
" </td>",
" 34",
" </td>",
" 14",
" </td>",
" 4",
" </td>",
" 0.002*",
" </td>",
" </tr>",
" <tr>",
" Somatization disorder",
" </td>",
" 23",
" </td>",
" 10",
" </td>",
" 0",
" </td>",
" 0.004",
" </td>",
" </tr>",
" <tr>",
" Behavior/character",
" </td>",
" <td>",
" 27",
" </td>",
" <td>",
" 14",
" </td>",
" <td>",
" 13",
" </td>",
" <td>",
" 0.23",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" Probability of meeting criteria for at least one diagnosis in this category:
P<0.01 after Bonferroni correction, FM patients vs. controls; P<0.05, FM
nonpatients vs controls.",
" </div>",
" Adapted from: Aaron, LA, Bradley, LA, Alarc—n, GS, et al, Arthritis
Rheum 1996; 39:436.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6350="Boy with measles";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=ID
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=ID
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" Boy with measles",
" </div>",
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" </div>",
" </div>",
" Source: Centers for Disease Control and Prevention.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var title_f6_12_6351="Lg airway obstruct PFT";
" ©2013 UpToDate",
" <sup>",
" ®",
" </sup>",
" </div>",
" <a href=\"?imageKey=ONC
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=ONC
" Print",
" </a>",
" </a>",
" Email",
" </a>",
" </div>",
" </div>",
" Large airway obstruction noted on pulmonary function",
" </div>",
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7Pkz6NCiR5Mubfo06tSqV7Nu7fo17NiyZ9Oubfs27ty6d/Pu7fs38ODChxMHHhAAOw==);\">",
" </div>",
" Flow volume loop showing flattening of the expiratory portion and normal
contour to the inspiratory",
" <br>",
" portion (variable intra-thoracic obstruction). The curve improved after
bronchoscopic treatment.",
" </div>",
" Reproduced with permission from: Midthun, DE, et al. Clinical presentation
of lung cancer. Lung Cancer 1996; :421. Copyright © Elsevier Science, Inc.",
" </div>",
" </br>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");

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