java barcode library open source Carcinoma of the Breast in Objective-C

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2 Carcinoma of the Breast
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Cancer of the breast (see also 16) is diagnosed approximately once in 3500 pregnancies Pregnancy may accelerate the growth of cancer of the breast, and delay in diagnosis affects the outcome of treatment Inflammatory carcinoma is an extremely virulent type of breast cancer that occurs most commonly during lactation Prepregnancy mammography should be encouraged for women over age 35 who are anticipating a pregnancy Breast enlargement during pregnancy obscures parenchymal masses, and breast tissue hyperplasia decreases the accuracy of mammography Any discrete mass should be evaluated by aspiration to verify its cystic structure, with fine-needle biopsy if it is solid A definitive diagnosis may require excisional biopsy under local anesthesia If breast biopsy confirms the diagnosis of cancer, surgery should be done regardless of the stage of the pregnancy If spread to the regional glands has occurred, irradiation or chemotherapy should be considered Under these circumstances, the alternatives are termination of an early pregnancy or delay of therapy for fetal maturation
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3 Choledocholithiasis, Cholecystitis, & Idiopathic Cholestasis of Pregnancy
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Severe choledocholithiasis and cholecystitis are not uncommon during pregnancy When they do occur, it is usually in late pregnancy or in the puerperium About 90% of patients with cholecystitis have gallstones; 90% of stones will be visualized by ultrasonography Symptomatic relief may be all that is required Conventional gallbladder surgery in pregnant women should be attempted only in complicated cases (eg, obstruction), because it may increase the perinatal mortality rate to about 15% Cholecystostomy and lithotomy may be all that is feasible during advanced pregnancy, cholecystectomy being deferred until after delivery On the other hand, withholding surgery may result in necrosis and perforation of the gallbladder and peritonitis Cholangitis due to impacted common duct stone requires surgical removal of gallstones and establishment of biliary drainage Endoscopic retrograde cholangiopancreatography and endoscopic retrograde sphincterotomy can be performed safely in pregnant women if precautions are taken to minimize exposure to radiation In the early to mid second trimester, laparoscopic cholecystectomy can be performed with minimal maternal morbidity and no fetal mortality
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Elective major surgery should be avoided during pregnancy Normal uncomplicated pregnancy does not alter operative risk except as it may interfere with the diagnosis of abdominal disorders and increase the technical problems of intra-abdominal surgery Abortion is not a serious hazard after operation unless peritoneal sepsis or other significant complications occur During the first trimester, congenital anomalies may theoretically be induced in the developing fetus by hypoxia Thus, the second trimester is usually the optimal time for operative procedures
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1 Appendicitis
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Appendicitis occurs in about 1 of 1500 pregnancies Diagnosis may be difficult, since the appendix is often carried high and to
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Passive immunization against hemolytic disease of the newborn is achieved with Rho(D) immune globulin, a purified concentrate of antibodies against Rho(D) antigen The Rho(D) immune globulin (one vial of 300 mcg intramuscularly) is given to the mother within 72 hours after delivery (or spontaneous or induced abortion or ectopic pregnancy) The antibodies in the immune globulin destroy fetal Rh-positive cells so that the mother will not produce anti-Rho(D) During her next Rh-positive gestation, erythroblastosis will be prevented An additional safety measure is the routine administration of the immune globulin at the 28th week of pregnancy The passive antibody titer that results is too low to significantly affect an Rh-positive fetus The maternal clearance of the globulin is slow enough that protection will continue for 12 weeks Hemolytic disease of varying degrees, from mild to serious, continues to occur in association with Rh subgroups (C, c, or E) or Kell, Kidd, and other factors Therefore, the presence of atypical antibodies should be checked in the third trimester of all pregnancies
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Matijevic R et al Diagnosis and management of Rh alloimmunization Fetal Diagn Ther 2005 Sep Oct;20(5):393 401 [PMID: 16113560]
Idiopathic cholestasis of pregnancy is due to a hereditary metabolic (hepatic) deficiency aggravated by the high estrogen levels of pregnancy It causes intrahepatic biliary obstruction of varying degrees The rise in serum bile acids is sufficient in the third trimester to cause severe, intractable, generalized itching and sometimes clinical jaundice There may be mild elevations in blood bilirubin and alkaline phosphatase levels The fetus is also threatened by this condition An increased incidence of preterm delivery has been reported as well as unexplained intrauterine fetal demise For this reason, antenatal surveillance of the fetus is mandatory in patients with this diagnosis Resins such as cholestyramine (4 g orally three times a day) absorb bile acids in the large bowel and relieve pruritus but are difficult to take and may cause constipation Their use requires vitamin K supplementation Limited but very encouraging experience has been reported with ursodeoxycholic acid, 16 mg/kg/d orally for 3 weeks, or dexamethasone, 12 mg/d orally for 7 days The disorder is relieved once the infant has been delivered, but it recurs in subsequent pregnancies and sometimes with the use of oral contraceptives
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