This pat ient has a chlamydial infection buy discount avana line erectile dysfunction medicine pakistan, which is more common than gonorrheal involvement; accordingly cheap 100mg avana with amex erectile dysfunction herbs a natural treatment for ed, her gonorrheal culture was negat ive. Chlamydial endocervical infect ion has not been proven to cause adverse problems with pregnancy, such as preterm labor or pret erm premat ure rupt ure of membranes. Interestingly, the erythromycin eye ointment given at bir t h d oes n ot pr event ch lamyd ial conju n ct ivit is, alt h ou gh it d oes pr ot ect against gonococcal eye infect ion. Babies wit h documented chlamydial ophthalmic infect ions are given oral eryt hromycin for 14 days. Because it is mainly neonat al disease, that is the issue, an important time to screen for the organism would be the third trimester, close to the time of delivery. Treatment for the pregnant patient includes eryt hromycin or amoxicillin for 7 days or azit hromycin as a one-t ime dose. It is one of the most common sexually transmitted organisms in the Unit ed St at es, causing uret h rit is, mucopurulent cer vicit is, and lat e post part um endomet rit is. Vert ical transmission may occur during the labor and delivery process, leading to neo- natal conjunctivitis or pneumonia. It is unclear whether chlamydial infection of the cervix is associated with preterm labor or preterm rupture of membranes; thus, the main concern is for the neonate. Eye prophylaxis is effective for pre- ven t in g go n o co ccal co n ju n ct ivit is b u t n o t ch lam yd ial in volvem en t. Chlamydial conjunctivitis is now t he most common cause of conjunctivitis in t he first month of life. Lat e post par t um en domet r it is, occur r in g 2 t o 3 weeks aft er deliver y, is associated with chlamydial disease. Some risk factors for chlamydial infections include unmarried status, age under 25 years, multiple sexual partners, and late or no prenatal care. The dis- ch ar ge is oft en d ifficu lt t o d et ect becau se of the in cr eased cer vical mu cu s in pr eg- nancy. Tet racycline and doxycycline are cont rain dicat ed in pregnan cy becau se of the possibilit y of st ain in g of the n eona- tal teeth. Because reinfection is common, repeat testing is recommended in the third trimester. G onococcal infect ion may complicat e pregnancy, especially in t eens or t h ose wit h a history of sexually t ransmitted disease. Gonococcal cervicit is is associ- ated with abort ion, preterm labor, preterm premature rupture of membranes, ch or ioam n ion it is, n eon at al sep sis, an d p ost par t u m in fect ion. D issem in at ed gon ococcal d isease is m or e com m on in the pr egn ant wom en (esp ecially the sec- ond or third trimester), presenting as pustular skin lesions, arthralgias, and sept ic art h rit is. Unt reat ed gonococcal opht h almia can progress t o corneal scar- ring and blindness. T hus, t he usual t reat ment for gonococcal cervicit is is ceft ri- axone int ramuscularly and an addit ional ant ibiot ic for C. Furthermore, t he unborn fetus may become infect ed eit h er by t ransplacent al passage or during the delivery process. Initially, patients may either be asymptomatic or have symptoms that mimic a mononucleosis-like illness. A positive screening test is followed with a confirmatory test, eit her a Western blot or an immunofluorescence assay. The st andard antibody tests may t ake 3 to 5 days, while the rapid test s return results in minutes to hours. T here continues to be correlation between maternal dis- ease st age at t he t ime of diagnosis wit h t he viral load and t ransmission rat es. W h en loads are reduced to undetectable levels, transmission to the fetus becomes uncom- mon. In pregnancy, the viral load should be evaluated monthly until it is no longer detect- able. Combination retroviral therapy decreases the risk of perinatal transmission to < 2%, and the best route of delivery is not clear. There is some evidence that cesar ean d eliver y can fu r t h er d ecr ease ver t ical t r an sm ission, but cesar ean d eliver y increases mat ernal risks of infect ion and h emorrhage. Patients should have regular monit oring of liver funct ion t est s and blood count s t o det ect toxicit y. He p a t it is The s t in g HepatitisBsurfaceantigen testingisrecommended for allpregnant patients. Those wit h co-infect ion should be t reated with ant iviral agent such as tenofovir and lami- vu d in e. I n fan t s sh o u ld r eceive h ep at it is B im m u n o glob u lin ( Ig) at b ir t h an d st ar the vaccination within 12 hours of birth. Deciding whether to treat hepatitis C with interferon and/ or ribavirin in pregnancy is complicated; ribavirin is associat ed wit h fet al anomalies when given around the time of conception of both men and women (category X). It h as a p r o p en sit y fo r t r an sit io n al an d co lu m n ar ep it h elia. Erythromycin eyedrops are an effective means of preventing chlamydial conju n ct ivit is. W hich of the following is the most likely met h od that the pat ient became in fect ed? Chlamydia is not typically seen on Gram stain because it is an intracel- lular organism. It does h ave a propensit y for columnar and t ransit ional epi- thelia, and it is a leading cause of preventable blindness worldwide. H owever, the pr esent at ion of t he pneumonia is not t ypically associat ed wit h high fever or sepsis. Chlamydia is an obligate intracellular organism associated with late postpartum endometritis and has a long replication cycle. Erythromycin eyedrops are an effect ive means of prevent ing gonococcal eye infect ion but chlamydial infection must be treated systemically with erythromycin. Gonococcal cervicitis is more likely to disseminate during pregnancy, and a pat ient may present wit h sept ic art hrit is, art hralgias, and pustular skin lesions. O ral amoxicillin is well t oler at ed an d effect ive t reat ment of ch lamydial cer- vicitis in pregnancy. Erythromycin estolate can lead to liver dysfunction in pregnancy; thus, the estolate salt is contraindicated in pregnant women. D oxycyclin e, or t et r acyclin e, is cont r ain d icat ed in pr eg- nancy because of the possibility of staining neonatal teeth. Ciprofloxacin is also contraindicated in pregnancy because it may lead to neonatal musculoskeletal problems. Because labor has already begun, elective cesarean delivery will not affect vertical transmission. In other words, the cesarean would need to be performed prior to rupture of membranes or labor to effectively decrease vertical transmis- sion. Intravenous Z D V and minimizing trauma to the baby, such as avoiding fet al scalp elect rode, int raut erin e pressure cat h et ers, forceps, an d vacuum deliver y, is advisable.

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Blood1 pressure is also increased because epinephrine promotes alpha -mediated1 vasoconstriction buy avana 100mg online impotence zoloft. In addition to increasing blood pressure avana 50 mg free shipping erectile dysfunction diabetes type 2 treatment, vasoconstriction helps suppress glottal edema. Individuals who are prone to severe allergic responses should carry an epinephrine autoinjector (e. Antihistamines are not especially useful against anaphylaxis because histamine is only one of several contributors to the reaction. Properties of Representative Adrenergic Agonists Our aim in this section is to establish an overview of the adrenergic agonists. The information is presented in the form of “drug digests” that highlight characteristic features of representative sympathomimetic agents. Some of these drugs are used in specialty areas; however, the choices of representative drugs will increase understanding of adrenergic receptor activation. As noted, there are two keys to understanding individual adrenergic agonists: (1) knowledge of the receptors that the drug can activate and (2) knowledge of the therapeutic and adverse effects that receptor activation can elicit. By integrating these two types of information, you can easily predict the spectrum of effects that a particular drug can produce. Unfortunately, knowing the effects that a drug is capable of producing does not always indicate how that drug is actually used in a clinical setting. Similarly, although isoproterenol is capable of producing uterine relaxation through beta activation, it is no longer used for this purpose because2 safer drugs are available. Because receptor specificity is not always a predictor of the therapeutic applications of a particular adrenergic agonist, for each of the drugs discussed next, approved clinical applications are indicated. Epinephrine • Receptor specificity: alpha, alpha, beta, beta1 2 1 2 • Chemical classification: catecholamine Epinephrine [Adrenalin, others] was among the first adrenergic agonists employed clinically and can be considered the prototype of the sympathomimetic drugs. Therapeutic Uses Epinephrine can activate all four subtypes of adrenergic receptors. As a consequence, the drug can produce a broad spectrum of beneficial sympathomimetic effects: • Because it can cause alpha -mediated vasoconstriction,1 epinephrine is used to (1) delay absorption of local anesthetics, (2) control superficial bleeding, and (3) elevate blood pressure. Pharmacokinetics Absorption Epinephrine may be administered topically or by injection. After subcutaneous injection, absorption is slow owing to epinephrine-induced local vasoconstriction. Inactivation Epinephrine has a short half-life because of two processes: enzymatic inactivation and uptake into adrenergic nerves. Adverse Effects Because it can activate the four major adrenergic receptor subtypes, epinephrine can produce multiple adverse effects. Hypertensive Crisis Vasoconstriction secondary to excessive alpha activation can produce a1 dramatic increase in blood pressure. Because of the potential for severe hypertension, patients receiving parenteral epinephrine must undergo continuous cardiovascular monitoring with frequent assessment of vital signs. Dysrhythmias Excessive activation of beta receptors in the heart can produce dysrhythmias. Angina Pectoris By activating beta receptors in the heart, epinephrine can increase cardiac work1 and oxygen demand. Provocation of angina is especially likely in patients with coronary atherosclerosis. If extravasation occurs, injury can be minimized by local injection of phentolamine, an alpha-adrenergic antagonist. By causing breakdown of glycogen secondary to activation of beta receptors in2 liver and skeletal muscle. If hyperglycemia develops, dosage adjustments will need to be made for medications used to manage diabetes. Tricyclic Antidepressants Tricyclic antidepressants block the uptake of catecholamines into adrenergic neurons. Accordingly, patients receiving a tricyclic antidepressant may require a reduction in epinephrine dosage. General Anesthetics Several inhalation anesthetics render the myocardium hypersensitive to activation by beta agonists. When the heart is in this hypersensitive state,1 exposure to epinephrine and other beta agonists can cause tachydysrhythmias. Beta-Adrenergic Blocking Agents Drugs that block beta-adrenergic receptors can prevent beta-adrenergic receptor activation by epinephrine. The EpiPen is an epinephrine autoinjector, one of three brands available in the United States. Every year, anaphylaxis kills about 6000 Americans: 125 who have food allergies, between 40 and 400 who have venom allergies, and more than 5400 who have penicillin allergy. EpiPen Description and Dosage The EpiPen autoinjector is a single-use delivery device, featuring a spring- activated needle, designed for intramuscular injection of epinephrine. If one injection fails to completely reverse symptoms, a second injection (using a second EpiPen) may be given. EpiPen Storage and Replacement Epinephrine is sensitive to extreme heat and light, so the EpiPen should be stored at room temperature in a dark place. This is not to infer that the device should be left in this environment until needed; when the patient will be in an area where an encounter with an antigen is possible, it is essential to take the EpiPen along. The factory-issue storage tube provides additional protection from ultraviolet light. If the epinephrine solution turns brown, if a precipitate forms, or if the expiration date has passed, the unit should be replaced. Anyone who has experienced a severe, systemic allergic reaction should always carry at least one epinephrine autoinjector. To prevent a full-blown reaction, epinephrine should be injected as soon as early symptoms appear (e. People who do not carry an EpiPen, and hence must wait for an emergency response team, greatly increase their risk for death. The EpiPen autoinjector is a tubular device with three prominent external features: a black tip (the needle comes out through this end), a clear window (for examining the epinephrine solution), and a gray cap (which prevents activation until being removed). Jab the device firmly into the outer thigh, at an angle perpendicular to the thigh, and hold it there for 10 seconds. To ensure the injection was made, examine the used EpiPen: if the needle is projecting through the black tip, the procedure was a success; if the needle is not projecting, jab the device in again. The effects of epinephrine begin to fade in 10 to 20 minutes, and anaphylactic reactions can be biphasic and prolonged. Hospital staff should be informed that epinephrine has been injected and should be shown the used EpiPen (to confirm the dosage). The injection itself may cause discomfort, and the epinephrine may cause tachycardia, palpitations, and a feeling of nervousness.

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Gunter and Friedman24 described the the support and strength of the lateral nasal wall; however discount avana 200mg amex otc erectile dysfunction pills that work, alar use of lateral crural strut grafts with or without lateral crural rim grafts are placed in a nonanatomic position and are largely repositioning to address cephalic positioning of the lateral crus limited to the treatment of external nasal valve collapse buy avana in india erectile dysfunction 5k. Oktem et al25 described repositioning of procedure can be performed via an external or endonasal rhi- the lateral crus with a cartilage Z-plasty technique in which the noplasty approach. A precise pocket along the alar margin is lateral crus on each side is transected and the anterior segment fashioned and an alar rim graft (usually 2 to 3mm wide and 1 attached to the domes is sutured to the caudal aspect of the to 2cm long) is placed within the pocket. No suture is necessary posterior segment, thus repositioning the majority of the lateral if an appropriate pocket is fashioned; however, a suture can be crus and providing more support to the external nasal valve. Similar to normally positioned lateral crura secondary to weakness of the ala rim grafting, Rohrich et al28 performed a retrospective cartilage, which can be congenital, iatrogenic, or secondary to review of 123 patients undergoing alar rim grafting (termed trauma or infection. Multiple surgical techniques have been “alar contour graft”) during a 6-year period and noted that 91% described to bolster support of the lateral crus, thus preventing of patients experienced correction of their alar notching or inspiratory collapse of the external nasal valve. Boahene and Hilger29 retrospec- monly used techniques utilized to bolster the support of the tively reviewed 150 rhinoplasty cases over a 1-year period and external nasal valve and the lateral crus of the lower lateral car- identified 31 cases (21%) in which alar rim grafting was used. In all cases in which alar rim grafting was utilized for internal nasal valve collapse. Alar batten grafts are commonly external nasal valve collapse, there was increased alar support fashioned from septal or conchal cartilage and are placed in an and decreased external nasal valve collapse noted postopera- appropriately sized pocket at the site of maximal collapse of the tively without any complications in the series. Gunter and Friedman24 described the use of lateral 63 patients undergoing placement of alar batten grafts for crural strut grafts placed underneath the lateral crus after dis- either internal or external nasal valve collapse or both. The section of the vestibular skin in patients with weakness or authors noted that 98% of patients noted improvement in their cephalic malpositioning of the lateral crus. A cartilage graft harvested from the ear or septum is placed in an appropriately sized pocket spanning the pyriform aperture and overlapping at least the medial aspect of the lateral crura of the lower lateral cartilages. Cartilage grafts are sutured to the underside of the lower lateral crura of the lower lateral cartilages after elevating the vestibular skin. A graded approach to repairing the technique and advocate the use of this technique for alar con- stenotic nasal vestibule. Lateral crural steal and lateral crural overlay: an objec- The nasal tip is a complex area that has significant implications tive evaluation. Arch Otolaryngol Head Neck Surg 1999; 125: 1365–1370 for functional and aesthetic outcomes following rhinoplasty. Tongue-in-groove technique and septorhinoplasty: A 10-Year Abnormalities of the nasal tip can lead to static or dynamic col- Experience. The tongue-in-groove technique in septorhi- lapse of the external nasal valve, leading to nasal obstruction noplasty. Arch Facial Plast Surg 1999; 1: 246–256, dis- and aesthetic abnormalities, in turn leading to the appearance cussion 257–258 of a boxy, bulbous, ptotic, and/or pinched tip. Septal extension grafts: a method the nasal tip; however, no single technique can be utilized to ofcontrolling tip projection shape. Modified back-to-back autogenous conchal cartilage familiar with multiple techniques to address both functional graft for caudal septal reconstruction: the medial crural extension graft. Arch and aesthetic abnormalities of the nasal tip to achieve optimal Facial Plast Surg 2011; 13: 20–25 outcomes. The two essential elements for planning tip surgery in primary References and secondary rhinoplasty: observation based on review of 100 consecutive patients. Plast Reconstr Surg 1997; 99: 943–952, discus- 1986; 112: 726–728 sion 953–955 [5] Pitanguy I. Cartilage Z plasty on lateral crus for treat- 2001; 107: 264–266 ment of alar cartilage malposition. Applications of the M-arch model in nasal tip refine- of alar rim deformities in rhinoplasty. Alar rim grafting in rhinoplasty: indications, techni- the cantilevered spring model. Arch Facial Plast Surg 2009; 11: 285–289 271 Tip Rhinoplasty 35 Nuances in Tip odification: Specific Applications of Cartilage Splitting in Rhinoplasty Anil R. Shah and Minas Constantinides Division of lower lateral cartilages in rhinoplasty has long been inexperienced rhinoplasty surgeon but is often necessary to maligned for producing unnatural results and unpredictable achieve an acceptable rhinoplasty outcome. The original manifestation of this technique resulted help in analyzing recognition of these specific nasal deformities from the Goldman tip rhinoplasty, stereotyped by the nar- in which cartilage-splitting techniques may improve the ulti- rowed, pinched noses of previous decades. In addition, technical details will be given in recently, use of several modifications of this technique in the order for the reader to produce the achieved results. With proper execution of technique and appropriate selection of patients, lower lateral 35. Goldman originally described his technique in a 1957 land- Typically, in patients with excessively long lateral crura relative mark article. An overly long lateral crus refine and maintain natural nasal tip appearance without the may exist coincidentally or independently from the tension requirement of grafts or implants. Unfortunately, dividing the nose or overly long nasal septum and must be distinguished cartilage without reapproximation often led to tip asymmetries from a ptotic nasal tip. Since this first description, of the relationship between the lower lateral cartilages and newer insight into nasal tip dynamics has broadened the appli- septum. The ptotic nose will not have a downward snarl in cation and use of division of lower lateral cartilages as an appearance and the nasal tip support is often weak. On the Anderson originally described the nasal tripod theory to pro- other hand, in the patient with excess long lateral cruses, the vide a simple explanation of tip dynamics. Surgeons who neglect to address the long legs of the tripod, and the conjoined medial crura and caudal lateral cartilage with appropriate modification will invariably septal attachments correspond to the third leg. Kridel and Konior first described the tech- instance, techniques that augment or lengthen the medial cru- nique of lateral crural overlay. Shortening the medial crura or lateral crura are separated from the underlying vestibular disrupting their septal attachments without reduction of lateral mucosa. Then, precise division of the lateral crus lateral to crural length decreases projection and rotation of the nasal tip. Another technique, Shortening the lateral crura and maintaining or lengthening the described by Adamson and others, is to divide the attachments medial crural segment would be expected to increase rotation. For exam- The authors prefer to use nonabsorbable suture tied away ple, a thick-skinned ptotic nose with long lateral crura and from the vestibular mucosa. Preservation of vestibular mucosa short, weak medial crura may not rotate as expected with lat- is necessary to prevent possible cartilage erosion or infection. Conversely, in a patient with a binding sutures can be placed without difficulty and excess long medial crura and short lateral crura, counter-rotation may bulk is not created in the domal area. Proper nasal analysis allows the surgeon to identify Most patients with excessively long lateral cartilages tend to which area is problematic and the subsequent surgical solution. The exceptions are those with Recognition of variant nasal anatomy can be difficult for the long and convex lateral crura.

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P ubic h air combin gs buy avana american express impotence natural supplements, fin ger n ail scr apin gs buy avana 100 mg low cost impotence pronunciation, an d skin wash - ings need to be collected as well. Colposcopic evaluat ion with toluidine blue can assess microscopic abra- sions t hat may be missed on gross examinat ion. Collection of these samples and thor- ough documentation play a pivotal role from a legal and medical perspective, and any healthcare provider that does not feel comfort able proceeding with the neces- sary steps, must seek assist ance from experienced personnel (see Figure 31– 1 for algorit hm of t he examinat ion of a sexual assault vict im). Emergency contraceptives should be given within 72 hours of the assault, but may be effective if given within 120 hours. A serum pregnancy test must be documented in t he chart prior t o administering any met hod of cont racept ion t o rule out a pre- exist ing pregnancy. The most effective form of emergency contraception is the copper intrauterine device if inserted within 120 hours postcoital and patients may benefit from the lon g-t er m r et en t ion. There are three main regimens for oral emergency contraception: progestin- only pills, combined oral contraceptives, and antiprogesterone pills (Table 31– 1). Prophylactic antibiotics for sexually transmitted infections are indicated for ch lamydial, gon ococcal, an d t r ich om on al in fect ion s. Administering ceftriaxone 250mg intramuscularly in a single dose, metronidazole 2g orally in a single dose, as well as azithromycin 1g orally in a single dose or doxycycline 100mg twice daily orally for 7 days are the recommended treatment for these infections (see Table 31– 2). Addit ionally, H uman Papilloma Virus vaccine is recommended for female vict ims aged 9 to 26 years, and may be offered to the victim of sexual assault. Sexual assault leads to a variety of acute emotional reactions ranging from severe distress to numbing of emotions, anger, and denial. This syndrome is charact erized by an acute disorganized phase, then a delayed phase of organization. The acute phase lasts days to weeks and is characterized by physical reactions such as body aches, alt erat ions of appet it e and sleeping, and a variet y of emot ional react ions including anger, fear, anxiet y, guilt, humiliat ion, embarrassment, self-blame, and mood swings. The later phase occurs in the weeks to months following and is char- act erized by flashbacks, night mares, and phobias as well as somat ic and gynecologic symptoms. Victims of sexual assault are at increased risk for post -traumatic stress disorder, major depression, and contemplation of suicide, or actual suicide attempt. Rape survivors are also at increased risk for some chronic medical problems including chronic pelvic pain, fibromyalgia, and funct ional gast roint est inal disor- ders. It is important to consult with social workers and rape crisis counselors to provide immediate intervention, evaluate future emotional and safety needs, and to ensure proper follow-up. Rape crisis centers can provide ongoing support to vict im s an d a list of t h ese t yp es of r esou r ces sh ou ld b e p r ovid ed. Elder abuse can be physical, emotional, psychological, or sexual abuse, or many be in the form of neglect, abandonment, or financial exploit at ion. Contrary to common assumpt ions, most incidents of elder abuse does not happen in nursing homes or ot h er inst itut ional sett ings but usually take place at home and often the family, other household members, or paid caregivers are usually the abus- ers. Risk fact ors for elder abuse include cognit ive impairment, depression and anxi- et y. T here is no pat hognomonic sign of elder abuse as signs can vary and may be subt le, and the majorit y of cases go undet ect ed. It is import ant t o screen all elderly women in order t o ident ify vict ims and provide assist ance. A detailed social history can evaluate family structure, stability of social sup- ports, identify financial stressors, and substance abuse or mental health history. Patients reporting high levels of stress, depression, or anxiety, sleeping or eating difficulties may be the victims of abuse. Poor hygiene, weight loss, unkempt appearance, miss- ing assistive devices, and inappropriate attire may be some signs of neglect. Most st at es mandat e t hat h ealt h care providers report confirmed cases t o Adult Prot ec- tive Services so it is important to educate yourself on the laws in your state. Abuse creates potentially harmful situations and feelings of worthlessness, and isolates the elder person from those who can help. In t im a t e Pa r t n e r Vio le n c e Intimate partner violence occurs in every culture, country, and age group, and affect s individuals in all socioeconomic and religious backgrounds. Lifelong consequences exist including physical impair- ment, emotional trauma, chronic health problems, and even fat ality. Alcohol and/ or substance abuse is much more prevalent in women who are victims as well as men who commit violent acts. Becau se of the h igh pr evalen ce, the ob/ gyn ph ysician mu st b e p ar t icu lar ly attuned to this problem. Sensit ive, confident ial, but direct quest ioning is t he best approach: “Are you being hurt or t hreat ened by anyone? When homicide or child abuse is suspected, it is mandatory to notify the authorities. It must be reinforced to a victim of domestic abuse that they are not responsible for the abu se, an d sh ould be empowered t o learn about the resources an d suppor t services, needs to make their own decisions, and discussions held in confident ialit y (to the limits of the law). A safety plan may be discussed including packing a bag in advance, having personal document s ready, having an ext ra set of car/ house keys, est ablishing a code wit h friends/ family, and having a plan of where t o go. Nevertheless, even if the patient denies inti- mate partner violence, it is beneficial to discuss the issues in a caring manner and offer educat ional material. Penile-to-vaginal intercourse occurred and the patient states she does not believe a condom was used. Prior to prescribing emergency cont r acept ion, wh ich of the followin g is m ost imp or t ant t o or d er? The patient has advanced dementia and cannot give a history, but her son says there have been no problems. A red rash is not ed on t he int roit al region, and also some bruising on t he vulvar and perineal area. T h e C D C r eco m m en d s scr een in g of in t im at e p ar t n er violen ce o n ce d u r - ing t he pregnancy, usually at the first prenat al visit. Usually intimate partner violence lessens during pregnancy due to con- cer n about h u r t in g the fet u s. She has recently immigrat ed t o t he count ry and has not been vaccinat ed against h epat it is B. An eld er ly p a t ien t wh o h a s d em en t ia is a t r isk fo r eld er ab u s e, b eca u s e they have high needs and also cannot report the abuse. This patient has signs of neglect such as bedsores and unkempt appearance, and likely prolonged soil- ing wit hout diaper changes. N ot ificat ion of t he aut h orit ies is mandat ory in a sit uat ion such as t h is. Intimate partner violence increases in pregnancy and can lead to preterm delivery, low birth weight, and placental abruption. H omicide, usually in the first trimester, is the second leading cause of injury-related deaths to pregnant women after motor vehicle accidents. Ulipristal acetate: review of the efficacy an d safet y of a n ewly appr oved agent for emergency cont racept ion. Know the common presentations of ureteral and bladder injuries after gyne- cologic su r ger y.