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The duration of action of morphine is 4 to 5 hours when administered systemically to opioid-naïve individuals but considerably longer when injected epidurally because the low lipophilicity prevents redistribution from the epidural space buy online fluticasone asthma 999. Adverse effects Many adverse effects are common across the entire opioid class (ure 14 buy fluticasone 500mcg online asthma symptoms chart. With most mu agonists purchase fluticasone 100 mcg line asthma symptoms bronchitis symptoms, severe respiratory depression can occur and may result in death from acute opioid overdose order cheap fluticasone on-line asthma symptoms 4 dpo. Respiratory drive may be suppressed in patients with respiratory disorders such as obstructive sleep apnea, emphysema, or cor pulmonale, so close monitoring is necessary when using opioids. Tolerance and physical dependence Repeated use produces tolerance to the respiratory depressant, analgesic, euphoric, emetic, and sedative effects of morphine. Tolerance usually does not develop to miosis (constriction of the pupils) or constipation. Withdrawal produces a series of autonomic, motor, and psychological responses that can be severe, although it is rare that withdrawal effects cause death. Guidelines for opioid prescribing urge clinicians to avoid simultaneous prescribing of opioids and benzodiazepines. A black box warning also has been included on the labeling of both opioids and benzodiazepines to alert prescribers of this dangerous combination. Life-threatening respiratory depression and death have been reported in children who received codeine, mostly following tonsillectomy and/or adenoidectomy. Codeine is commonly used in combination with acetaminophen for management of pain. It is preferred over codeine in most situations where cough suppression is needed. Oxymorphone given parenterally is approximately ten times more potent than morphine, but when administered orally, the potency drops to about three times that of morphine. Oxymorphone is available in both immediate-release and extended-release oral formulations. Oxycodone is approximately two times more potent than morphine and is available in an immediate-release formulation, alone or in combination with acetaminophen, aspirin, or ibuprofen. It is preferred over morphine in patients with renal dysfunction due to less accumulation of active metabolites. Hydrocodone is the methyl ether derivative of hydromorphone, but is a weaker analgesic than hydromorphone, with oral analgesic efficacy comparable to that of morphine. This agent is often combined with acetaminophen or ibuprofen to treat moderate to severe pain. Fentanyl has 100-fold the analgesic potency of morphine and is used for anesthesia and acute pain management. The drug is highly lipophilic and has a rapid onset and short duration of action (15 to 30 minutes). Fentanyl is combined with local anesthetics to provide epidural analgesia for labor and postoperative pain. Many fast-acting transmucosal and nasal fentanyl products are available for cancer-related breakthrough pain in opioid-tolerant patients. The transdermal patch creates a reservoir of the drug in the skin and has a delayed onset of at least 12 hours and a prolonged offset. It is contraindicated in opioid-naïve patients and should not be used in management of acute or postoperative pain. Sufentanil and carfentanil are even more potent than fentanyl, whereas the other two are less potent and shorter acting. Sufentanil, alfentanil, and remifentanil are mainly used for their analgesic and sedative properties during surgical procedures requiring anesthesia. The drug is not used in clinical practice; however, it is of toxicological interest as it is used to lace heroin and has contributed to several opioid-related deaths. Therefore, it is useful in the treatment of both nociceptive and neuropathic pain. Methadone may also be used for opioid withdrawal and maintenance therapy in the setting of prescription opioid and heroin abuse. The withdrawal syndrome with methadone is milder but more protracted (days to weeks) than that with other opioids. Methadone induces less euphoria and has a longer duration of action than morphine. Understanding the pharmacokinetics of methadone is important to ensure proper use. After oral administration, methadone is biotransformed in the liver and excreted almost exclusively in the feces. Methadone is very lipophilic, rapidly distributed throughout the body, and released slowly during redistribution and elimination. This translates into a long half-life ranging from 12 to 40 hours, although it may extend up to 150 hours. Despite the extended half- life, the actual duration of analgesia ranges from 4 to 8 hours. Attainment of steady state can vary dramatically, ranging from 35 hours to 2 weeks, so dosage adjustments should occur only every 5 to 7 days. Upon repeated dosing, methadone can accumulate due to the long terminal half-life, leading to toxicity. Overdose is possible when prescribers are unaware of the long half-life, the incomplete cross-tolerance between methadone and other opioids, and the titration guidelines to avoid toxic accumulation. Methadone can produce physical dependence like that of morphine, but it has less neurotoxicity than morphine due to lack of active metabolites. It is used for acute pain and acts primarily as a κ agonist, with some μ agonist activity. Meperidine is very lipophilic and has anticholinergic effects, resulting in an increased incidence of delirium compared with other opioids. Meperidine has an active metabolite (normeperidine), which is potentially neurotoxic. Normeperidine is renally excreted, and in patients with renal insufficiency, accumulation of the metabolite may lead to delirium, hyperreflexia, myoclonus, and seizures. Due to the short duration of action and the potential for toxicity, meperidine should only be used for short-term (≤48 hours) management of pain. Partial Agonists and Mixed Agonist–Antagonists Partial agonists bind to the opioid receptor, but they have less intrinsic activity than full agonists (see Chapter 2). Drugs that stimulate one receptor but block another are termed mixed agonist–antagonists. In individuals who are opioid-naïve, mixed agonist–antagonists show agonist activity and are used to relieve pain. In the presence of a full agonist, the agonist–antagonist drugs may precipitate opioid withdrawal symptoms. Buprenorphine is very lipophilic and has a longer duration of action due to its high affinity for the opioid receptors when compared to morphine. Due to high affinity for the mu receptor, buprenorphine can displace full μ agonists, leading to withdrawal symptoms in an opioid-dependent patient.
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Hence the symptoms of shock are present only following a much greater fluid loss if this is hypotonic buy generic fluticasone 250 mcg online asthma treatment 7. A low urine volume and a high urine concentration together with thirst may be seen with all fluid loss; however thirst is noted more with hypotonic fluid loss generic 100 mcg fluticasone fast delivery asthma definition ats. The electrolyte content of his fluid loss through vomiting is shown in comparison with other gastrointestinal losses in the table below purchase fluticasone 500 mcg otc asthma definition 8 parts. Intestinal Sodium Potassium Chloride Bicarbonate secretion (mmol/L) (mmol/L) (mmol/L) (mmol/L) Gastric 20–60 14 140 0–15 Biliary 145 5 105 30 Pancreatic 125–138 8 56 85 Small bowel 140 5 125 30 Large bowel 60 15 40 – In a young person cheap fluticasone 250mcg overnight delivery asthma zafirlukast, the gastric fluid will have a low sodium concentration and zero bicarbonate with the ionic difference being filled by hydrogen ions – about 105 mmol/L. The extent of fluid loss may be assessed in previously fit people by the increase in haematocrit, total protein and albumin concentrations. However, where there is a background chronic disease, anaemia and hypoproteinaemia make interpretation more difficult. While it may indicate fluid depletion, an elevation in creatinine is also affected by pre-existing renal function. Although both the urea and creatinine are raised, the plasma and urine osmolalities indicate the kidney tubules are capable of concentrating urine, and the low urine sodium shows that tubular reabsorption of sodium is effective. The loss of hydrogen ions leaves an excess of bicarbonate in serum as normally this fluid would be reabsorbed and the effect on acid/base balance neutral. Although gastric fluid contains 5–20 mmol/L of potassium, this is not the major reason for the hypoka- laemia, although it does contribute. Poor kidney perfusion causes the release of renin, which then activates the angiotensin system and through this the secretion of aldosterone from the adrenal cortex. Aldosterone promotes the retention of sodium through the exchange of sodium for potassium or hydrogen ions (see ure 8. Furthermore, the exchange of sodium for hydrogen ions in the renal tubules generates bicarbonate, which is already in excess in plasma. Hence in this context, the exchange of sodium is mostly for potassium, thus generating the hypokalaemia. Note: As the plasma potassium falls in the extracellular fluid, potassium leaves the intracellular space to compensate. For this reason, the amount of potassium lost to cause a fall in plasma potassium is considerable – usually a fall of plasma potas- sium by 0. Although Hartmann’s solution is used extensively to cover loss from small bowel, the high chloride loss in this case requires the use of saline initially. This should not be replaced immediately as time must be given for equilibration between extracellular and intracellular spaces. However, more than 40 mmol will be required in the first 24 h and in a fit young person 100 mmol in 24 h is reasonable. Case 8: Man with severe vomiting 43 However, it will be important to check the electrolyte levels but more to ensure that potassium replacement is appropriate. When the kidneys are better perfused, the plasma urea and creatinine will fall, but only when the urine volume has increased sufficiently to excrete the high level of urea in the total body water. Blood alcohol concentrations of 2 g/L are associated with confusion, values of 3 g/L with stupor, 4 g/L with coma and 5 g/L may be fatal. This potentially fatal condition may be missed as there may not be a ketotic odour and Ketostix test may be negative. The possibility of this being due to non-alcoholic fatty liver disease, which is associated with diabe- tes, needs consideration. The elevation in lactate is due to poor oxygenation of tissues and is associated with the opiate-induced respiratory depression. Blood lactate is also elevated in paraceta- mol poisoning and if co-codamol has been taken, then both paracetamol concentra- tion in the blood and a positive screening test for opiates will be present. Another possibility is the effect of carbon monoxide which is associated with lactic acidosis, as is diabetic ketosis. Lactic acidosis is a metabolic acidosis and is defined as a blood lactate concentration above 5 mmol/L, while values between the upper limit of normal and 5. The causes of lactic acidosis may be divided into those associated with (1) hypoxic and (2) non-hypoxic causes. Treatment of lactic acidosis is primarily the removal of the underlying cause plus ensuring adequate oxygenation, and that perfusion is adequate. On suspicion of salicylate poisoning, blood gases are measured and blood samples sent to the laboratory. Calculate the anion gap for the second set of laboratory tests and comment on the reasons for the change. Salicylate toxicity initially will create a pure respiratory alkalosis because of direct stimulatory effects on the respiratory centre of the cerebral medulla. Compensatory mechanisms of renal bicarbonate retention do not respond sufficiently rapidly to move the pH towards normal. The alkalosis may induce tetany due to a fall in ionized calcium, although total (adjusted) serum calcium may remain within normal limits. However, increased glucose-6- phosphatase activity and hepatic glycogenolysis can also cause hyperglycaemia if large amounts of salicylate are ingested. A respiratory alkalosis may be associated with a range of clinical conditions which may be grouped by causative mechanisms as shown below: • Hyperventilation, e. The anion gap may be calculated as (sodium concentration + potassium concentra- tion) − (chloride concentration + bicarbonate concentration). The high lactic acid is the major cause of this, although there is a small input from salicylate itself. The rise in lactate is due to the effect of salicylate in uncoupling mitochondrial function so that metabo- lism relies on the conversion of glucose to pyruvate and lactate. Hence, lactate levels rise in the serum and a respiratory alkalosis is overcome by a metabolic acidosis. This patient has moderately severe salicylate poisoning, levels >500 mg/L indicate severe poisoning and >700 mg/L may be lethal. Case 10: Young woman with aspirin overdose 51 Paracetamol levels must also be checked as this may also have been taken and salicylate levels may need to be repeated after 2 hours as salicylate absorption can continue during this time. More severe salicylate poisoning may require urine alkalinization with bicarbonate/potassium chloride and dialysis may be needed with very high salicylate levels. In A&E, samples were taken for routine tests and a dextrose infusion commenced prior to transfer to the medical assessment unit where blood tests were repeated 6 h later. The laboratory indicators of sepsis are leukocytosis (white cell count >12 000 × 109/L) or leukopenia (white cell count <4000 × 109/L), hyperglycaemia (plasma glucose >6. The rise in creatinine is greater than 26 μmol/L indicating acute kidney injury even though the values remain within the reference intervals. The fall in transferrin and iron with low normal transferrin saturation but raised fer- ritin is typical of the response to sepsis. The mechanism for the fall in iron levels is through the increased production of hepcidin by the liver. Hepcidin inhibits ferroportin on the basal side of enterocytes thus reducing iron absorption from the gut. It occurs because of glucose mobilization via glycogenolysis and gluconeogenesis induced by high circulating levels of glucagon and catecholamines and the inhibition of insulin secretion (probably catecholamine mediated) in the early stages of the metabolic response to injury. At later stages in the metabolic response to injury, insulin Case 11: Asthmatic male with cough 55 resistance dominates the metabolic response.
Because of high levels of urinary excretion discount fluticasone 100 mcg with mastercard asthma kod djece, fluconazole is generally preferred over caspofungin purchase fluticasone 100mcg free shipping asthma treatment by zubaida apa, other β-glucan inhibitors discount 100mcg fluticasone free shipping asthma treatment 2 year old, and other triazoles (such as voriconzole buy fluticasone uk asthma treatment reliever, itraconazole, or posaconzole) in the treatment of genitourinary candidiasis [48,70]. Bladder irrigation with a short course of amphotericin B (2 days) remains a viable treatment option in catheterized patients with candiduria in the absence of evidence of disseminated candidiasis . Candida species are normal inhabitants of the vaginal tract of women and may contaminate inadequately collected urine specimens. These organisms are of marginal clinical significance and frequently disappear on removal of the urinary catheter without any specific antifungal therapy . In a detailed survey of 861 patients with funguria by the national mycoses study group, no treatment was given in 155 patients and funguria resolved spontaneously in 76% of these patients . Candida cystitis may produce a friable white pseudomembrane on the bladder mucosa similar to the findings of oral thrush. Papillary necrosis, fungus ball formation, urinary obstruction, bladder rupture, and perinephric abscess have all been described from ascending infection with Candida species [62,63]. Candida infection of the upper urinary tract may arise from hematogenous dissemination of Candida organisms from extrarenal sites. Microabscesses of the renal parenchyma with subsequent candiduria are frequently present among those with disseminated candidiasis. A positive urine culture for Candida species may be the first indication of disseminated candidiasis for the critically ill patient. Quantitative culture of the urine has been used in an attempt to determine the clinical ramifications of candiduria. Unfortunately, the quantitative colony counts of Candida species in the urine do not have the same diagnostic and prognostic implications as quantitative bacteriology of the urine [48,63]. The finding of urinary casts made up of Candida elements is of diagnostic significance and indicates invasive upper tract candidiasis. Candiduria associated with a fungus ball in the urinary collecting system dictates the need for antifungal therapy, as does papillary necrosis or abscess formation within the renal parenchyma. Evidence of concomitant infection with Candida organisms in other organ systems increases the likelihood of the significance of Candida isolates in the urine. Disseminated candidiasis should be considered for patients with repeated and unexplained Candida isolates in the urinary tract [66–68]. Biomarker plasma sample evidence of disseminated candidemia such as an elevated β-D-glucan level can assist in early detection of systemic candidiasis in septic patients . The discontinuation of antibacterial agents, removal of immunosuppression, or removal of urinary catheters may be sufficient to spontaneously clear candiduria in medically stable patients . This triazole compound is water soluble, available as oral or intravenous formulations, and is excreted as the active compound in the urine. Posaconazole, itraconazole, caspofungin, and voriconazole might be useful despite the fact that they are excreted by the kidney and do not uniformly achieve fungicidal levels in the urine. Tissue levels in the upper urinary tract might still be sufficient to treat genitourinary candidiasis for selected patients, but clinical experience is limited . Fluconazole also provides systemic antifungal activity when unrecognized disseminated candidiasis is present. It is now recommended that antifungal susceptibility testing be performed for serious Candida infections for fluconazole, itraconazole, and flucytosine . Resistance among Candida albicans isolates is increasingly recognized and these findings emphasize the necessity of antifungal susceptibility testing . Candida krusei is intrinsically resistant to fluconazole; Candida lusitaniae is resistant to amphotericin B; and Candida glabrata is variably sensitive to azole antifungal agents. Amphotericin B in vitro susceptibility testing is technically difficult and the methodology has not yet been standardized for routine clinical laboratory testing . High doses of amphotericin B instilled into the bladder is potentially toxic to uroepithelial cells; however, a 2-day infusion of 50 mg of amphotericin B in 1,000 cc of sterile water per day is effective ; a single systemic dose of amphotericin B can also clear candiduria . Systemic fluconazole or amphotericin B is indicated in candiduria patients with suspected systemic candidiasis, renal abscess formation, and fungus balls within the urinary collecting system . A short course of fluconazole at 200 mg orally followed by 100 mg daily for 5 to 7 days is generally sufficient for the treatment of Candida  cystitis while upper urinary tract disease is generally treated with 200 to 400 mg fluconazole for 2 weeks . Equipment and scanning technique for ultrasonography of the kidney and bladder are reviewed elsewhere in this textbook (Chapter 200, Acute Kidney Injury). Characteristic Ultrasonography Findings Uncomplicated pyelonephritis results in enlargement of the kidney but otherwise has no specific findings. Perinephric abscess results in a heterogeneous crescent-shaped collection that surrounds the kidney, while renal abscess appears as a complex hypoechoic mass with irregular thick walls. Kidney stones may complicate a kidney infection; they are identified as strongly hyperechoic structures within the kidney with associated acoustic shadowing. Emphysematous pyelonephritis results in hyperechoic foci within the parenchymal/pelvocalyceal area with associated comet tail artifact or mild acoustic shadowing. Lizan-Garcia M, Peyro R, Cortina M, et al: Nosocomial surveillance in a surgical intensive care unit in Spain, 1996–2000: a time-trend analysis. Svanborg C, Frendeus B, Godaly L, et al: Toll-like receptor signaling and chemokine receptor expression influence the severity of urinary tract infection. Cai T, Mazzoli S, Mondaini N, et al: the role of asymptomatic bacteriuria in young sexually active with recurrent urinary tract infection: to treat or not to treat? Cai T, Nesi G, Mazzoli S, et al: Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections. Noskin G, Siddique F, Stosor V, et al: Successful treatment of persistent vancomycin-resistant Enterococcus faecium bacteremia with linezolid and gentamicin. López-López G, Pascual A, Martínez-Martínez L, et al: Effect of a siliconized latex urinary catheter on bacterial adherence in human neutrophil activity. Martino P, Girmenia C, Venditti M, et al: Candida colonization and systemic infection in neutropenic patients. Apisarnthanarak A, Rutjanawech S, Wichansawakun S, et al: Initial inappropriate urinary catheters use in a tertiary-care center: incidence, risk factors, and outcomes. Many cases of bacterial meningitis also fit this definition of encephalitis due to the occurrence of mental status changes, seizures, or coma. Focal infections, such as brain abscesses, may present more as space-occupying lesions than with classical infectious signs or symptoms. This must be balanced with the need to administer antibiotics promptly; delays as short as 3 hours have been shown to lead to unfavorable outcomes [1,2]. Delayed or inadequate treatment increases the risk of death or significant neurological impairment . Historically, bacterial meningitis in the United States has been primarily caused by five organisms: Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes, Haemophilus influenzae, and group B streptococcus. The case fatality rate is 20% to 30% in adults and survivors have approximately a 30% risk of sequelae [9,10]. Routine infant immunization has also reduced the incidence of pneumococcal meningitis in older children and adults due to a reduction in S. Incidence peaks in three age groups: infants and children under 5 years, adolsescents/young adults (16 to 21 years), and adults over 65 years . It is the one form of bacterial meningitis associated with epidemic spread, though the majority of cases in the United States are sporadic [9,16].
Laparoscopic 2 Modified radical hysterectomy; removal of medial 50% of the cardinal and uterosacral ligaments; uterine vessels are pelvic lymphadenectomy followed by a deep cold‐knife divided medial to the ureter conization has also been proposed buy discount fluticasone 500mcg line asthmatic bronchitis quote, but high‐quality evi- 3 Equivalent to the classical Wertheim–Meigs operation; dence is still lacking buy 250 mcg fluticasone mastercard asthma symptoms for kids. If fertility is not an issue buy 250mcg fluticasone with visa asthma 4x4, radical wide radical resection of the parametrium and hysterectomy buy 100mcg fluticasone with mastercard asthma bronchitis natural treatment, or possibly simple hysterectomy and pel- paravaginal tissues; ureter dissected completely to vic lymphadenectomy, should be recommended. There lymph node dissection is as safe in the management of should be at least 5mm clear margin from the tumour. The pelvic lymph node dissection should include obtura- tor, internal, external and common iliac nodes. Para‐aortic Radical trachelectomy In other sites such as the breast lymphadenectomy is not mandatory. Chronic bowel and bladder problems that require medical Gynaecological oncologists have attempted to apply the or surgical interventions occur in up to 8–13% of women same principle for stage Ia2 and small‐volume stage Ib due to parasympathetic denervation secondary to surgi- cervical tumours by adopting more conservative fertility‐ cal clamping at the lateral excision margins. Advanced maternal age and bladder dysfunction requiring long‐term intermittent detection of early‐stage disease as a result of screening self‐catheterization is reported in 2. Lymphoedema as a late Radical trachelectomy was first described by D’Argent complication that usually develops in the first year after in the mid‐1980s and involves a radical excision of the surgery occurs in up to 15% of patients and is permanent. The commonest route of trachelec- can be quite severe and significantly affect quality of life tomy is the vaginal approach, though more recently some in 3% of patients. Sexual surgeons are favouring an abdominal or laparoscopic function and psychological issues such as grieving over approach that facilitates a greater excision of the para- loss of fertility, altered body image and reduced vaginal metrium. Intraoperative complications are reveals that more radical approaches offer no survival rare. Postoperatively, about one‐quarter of women suffer benefit and often lead to higher incidence of perioperative dysmenorrhoea or, less commonly, cervical stenosis, morbidity and chronic bladder and bowel dysfunction. The Piver–Rutledge classification for radical hysterec- Meta‐analyses and case series based on the vaginal tomy is widely used; newer classifications have also been approach have demonstrated recurrence rates of around proposed (Querleu–Morrow)  (Tables 61. The uterosacral and vesicouterine ligaments are not transected at a distance from the uterus. Vaginal resection is generally at a minimum, routinely less than 10 mm, without removal of the vaginal part of the paracervix (paracolpos) Type B Transection of the paracervix at the ureter. Partial resection of the uterosacral and vesicouterine ligaments, ureter is unroofed and rolled laterally, permitting transection of the paracervix at the level of the ureteral tunnel. At least 10 mm of the vagina from the cervix or tumour is resected Type C Transection of paracervix at junction with internal iliac vasculature system. Transection of the uterosacral ligament at the rectum and vesicouterine ligament at the bladder. Between 15 and 20 mm of vagina from the tumour or cervix and the corresponding paracolpos is resected routinely, depending on vaginal and paracervical extent Type D Laterally extended resection. Careful selection of patients is crucial as detailed assess- ment may optimize outcomes and minimize adverse Radical radiotherapy events. These decisions necessitate involvement of a multi- Radical radiotherapy aims to treat the primary tumour disciplinary specialized team with considerable experience. It is delivered by external‐beam radiotherapy (teletherapy) that intends to Stage Ib2 treat any pelvic spread and by intracavitary treatment Management of bulky Ib tumours (especially stage Ib2) is (brachytherapy) that targets the primary site. The chal- controversial as these tumours are characterized by high lenge of optimal dose planning is to cure the primary dis- rates of positive nodes and close surgical margins. Most ease and pelvic spread with the least possible morbidity centres offer chemoradiotherapy as opposed to surgery to bowel, bladder and sexual function. The external‐ but a few elect to operate; these centres have published beam radiotherapy sessions to the pelvis are delivered equivalent survival data. Extended radiotherapy After surgery, histological examination of the specimen involving the para‐aortic nodes increases morbidity with provides information on several prognostic factors that no significant survival benefit. Allowing Surgery with curative intent is not possible in women variations in exact schedule, dose of treatment and stage with advanced stages of disease. Decisions on continuing or ter- As expected, higher rates of short‐term and medium‐ minating the pregnancy and the modality of treatment term morbidity have been reported, although long‐term should be made on an individual basis. Follow‐up and management of recurrent disease Neoadjuvant chemotherapy Neoadjuvant chemotherapy is the use of chemotherapy the evidence on the role of post‐treatment surveillance in before definitive surgical treatment or radiotherapy. It the detection of recurrent disease is inconsistent, although has not been shown to be beneficial before radiotherapy follow‐up enables much more than just detection of recur- and current evidence does not support such an approach. It permits assessment of the complications of It has also been suggested that preoperative chemother- treatment and the psychological, physical and psychosex- apy could be used to shrink disease and allow resectabil- ual morbidity and provides reassurance. There is no role for ity of the tumour prior to radical surgery in inoperable cervical or vaginal vault cytology in the follow‐up period cases and that this approach may be superior to radical except in women who had fertility‐sparing procedures. The evidence demonstrates that this improves survival in operable cases and eliminates morbidity related to Cervical cancer in pregnancy unnecessary interventions in unsuitable patients. Before Cancer of the cervix affects 1 in 10 000 pregnancies and considering further treatment, histological diagnosis is represents about 1 in 34 cases of cervical cancer. The the symptoms may be attributed to the pregnancy and exact treatment depends on the primary treatment, the colposcopic assessment of the pregnant cervix is not site and stage of the recurrence, the presence of distant always easy; advice should be obtained from an experi- disease, its resectability, treatment‐related morbidity enced colposcopist. If invasion is suspected, an adequate and the effect on quality of life, and the patient’s general biopsy in the form of loop, knife or wedge cone should be health and wishes. The principles of management remain the same Women treated initially with surgery should be consid- and treatment is similar stage for stage. Traditionally, exenteration in some cases, provided the recurrence is cen- more advanced stages presenting before 20 weeks’ ges- tral with no distant recurrence. Careful selection of cases tation are treated immediately, those presenting after 28 and appropriate counselling is essential. In the hands of weeks are treated after delivery, while those presenting skilled surgeons and appropriate preoperative assessment, between 20 and 28 weeks remain in a grey zone. However, I disease, diagnosed after 20 weeks, delaying treatment up to one‐third of procedures are abandoned intraopera- until after delivery is often the most favourable option. Delivery around 32–34 weeks is justified after admin- istration of steroids to promote fetal lung maturation. Palliation Caesarean radical hysterectomy is recommended after delivery of the fetus by classical incision. Chemoradiation In progressive advanced cervical disease, urinary tract will cause spontaneous miscarriage or fetal death. Ureteric obstruction and impaired nia due to vaginal stenosis after chemoradiation. Faeces issues often need to be addressed by clinicians and in and urine diversion with nephrostomies and stenting some cases referral to a counsellor might be necessary . Chemotherapy with cisplatin is also palliative and should the future be restricted to primary late stage or recurrent cases that are not considered curable with other treatment options. The single greatest advance in the prevention of cervical It may increase life expectancy by a few months, but this cancer during the last decade has been the development must be balanced against quality of life. The use of neoadjuvant chemotherapy Psychological impact prior to fertility‐sparing techniques has also been Because cervical cancer usually affects young women, reported but further evidence is required on safety. Careful staging is important and allows selection ● the disease and its treatment can have a huge physical of the most appropriate treatment modality as the com- and psychological impact on women. Une alternative a conservative treatment for intraepithelial or early l’hysterectomie radicale dans le traitement de cancers invasive cervical lesions: systematic review and meta‐ infiltrants developpes sur la face externe du col uterin.
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