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By J. Ronar. Globe University. 2019.

Her research is Notes on Contributors 281 focussed on the study of the English language in academic and professional contexts 25mg clomiphene with mastercard menstruation yoga poses, with particular regard to the analysis of medical 25 mg clomiphene sale women's health center va beach, legal and tourism discourse clomiphene 100mg discount women's health center valdosta. Her most recent publications include: the volume Tourism Discourse: Professional, Promotional, Digital Voices (2013); and the papers ‘What Does he Think This is? She is co-author of a Dutch grammar (Ross/Koenraads: Grammatica neerlandese di base, Hoepli 2007) and co-editor of a volume on literary translation (Ross/Pos/Mertens (eds) Ieder zijn eigen Arnon Grunberg, Academia Press2012). Together with Marella Magris she has written several articles on medical translation, website communication in the healthcare sector as well as legal translation. His research activity and major publications deal with language for specific purposes and, more specifically, the application of genre and discourse analytical methods to a corpus-based study of legal- academic discourse and to the analysis of the linguistic, textual and pragmatic aspects of legal translation. He has also published in the field of academic discourse (Persuasion and Politeness in Academic Discourse, 2008, Genre Variation in Academic Communication.

In order to make an informed choice purchase clomiphene 100mg on-line breast cancer pins, the woman needs to understand the nature of the test itself order clomiphene 100mg mastercard pregnancy symptoms before missed period, as well as the advantages and disadvantages of not receiving the result should it be positive buy cheap clomiphene 50 mg on-line menstruation 8 weeks postpartum. They cite a case when a doctor was found in breach of duty for failing to inform a woman of the potential consequences of not agreeing to a cervical smear. In addition, the leaXet issued by the Department of Health, in circulation after 1994, does not refer to treatments available for reducing vertical transmission. In any case, the notion of passive consent, that is to say that consent is implied unless there is a verbal refusal, is ethically unsound and ‘a concept quite alien in English law’ (Brazier and Lobjoit, 1999: p. In clinics that pro- vide universal testing (see later), the women should have received the relevant information from a pre-test discussion with the midwife, and the 70 P. In one study only Wve per cent fully understood the nature of the testing, and a signiWcant proportion believed that they would be informed should the result be positive (Chrystie et al. The principle of autonomy is frequently infringed by the process of anonymized testing, and, as Brazier says, ‘Consent truly is a myth’ (Brazier and Lobjoit, 1999: p. The ethics of named testing The Department of Health’s Unlinked Anonymous Surveys Steering Group in 1989 rejected mass voluntary testing as an alternative to anonymized testing. As argued above, the beneWts of named testing, and the arguments in favour of truth-telling are further strengthened, particularly as third parties are placed at risk by non-disclosure. The majority of industrialized countries adopted a universal testing policy (whereby all women were oVered the test), and developed their own guide- lines. Women at high risk in ‘low-prevalence areas’ may well miss out; this resource allocation dilemma is one well known to all screening programmes, and diYcult to resolve. This merits further discussion, but suYce to say that if resources are available, there is a strong argument for recommending a universal policy for all pregnant women (Hudson et al. The American Medical Association recently voted in favour of mandatory testing of pregnant women, although mandatory testing is a legal requirement in only a few states such as Texas and New York (Phillips et al. The reasons for this include the following: ∑ ‘high status coercion’ by professionals (see below); ∑ imposed targets, placing health professionals under duress to maximize uptake; ∑ multiple tests, creating confusion; ∑ lack of time and resources to allow a discussion suYciently detailed for women to understand the nature and purpose of the test. A health professional occupies a position of authority, and if he or she recommends a test, many women would feel that it is not within their rights to refuse. The strongest factor inXuencing uptake, excluding the direct oVer of a test, has generally been the individual midwife interviewing the woman (Jones et al. These Wndings reinforce the hypothesis that consent is driven by the health professional’s agenda, and that routine testing may not always be fully voluntary. Women most at risk (aside from intravenous drug users) are from high-prevalence areas, particularly from sub-Saharan Africa, and their Wrst language is not English or any other Western language. Schott and Henley (1996) quote studies that show that women who speak little or no English are given fewer choices and less information, and that health professionals tend to be paternalistic and insensitive towards them, concluding that: ‘They cannot give genuinely informed consent’ (Schott and Henley, 1996: p. The individual is seen as an integral part of the family or community and a woman has to consult her spouse, or other members of the family, and even elders, before consenting to medical or surgical procedures (Schott and Henley, 1996; NuYeld Council on Bioethics, 1999; de Zulueta, 2001). There are no clear guidelines for how long pre-test discussion should take, but it seems unlikely that all the issues referred to can be discussed in such a short time span. They point out the conXicts for the health professionals in providing an ‘ideal’ pre-test counselling practice with ‘the time and cost constraints of busy practices and managed care plans’. Some tests, for example, for Down’s syndrome, are done with the implicit understanding that if they prove positive, the mother is expected to have an abortion. The empirical studies highlight the diYculty for the health professionals in delivering a culturally sensitive policy, whilst not depriving an at-risk group of advice which may be of particular value and relevance. Some would question how much the individual’s right to make a choice should be respected if this autonomy jeopardizes the future of the next generation. It can be argued that the women are hiding their heads in the sand, for sooner or later the disease will manifest itself, and they will have lost opportunities for themselves and their oVspring. For a trial to be ethical the researchers must be in a position of equipoise: they do not know which therapy will be the most eVective (Freed- man, 1987). The patient must not only understand the process of randomization, but also the risks and beneWts of treatment and non-treatment, and the treatments currently available. Lurie and Wolf also argue that the trials contravene existing guide- lines – in particular, the Declaration of Helsinki (World Medical Association, 1996) and the international ethical guidelines for biomedical research involv- ing human subjects of the Council for International Organizations of Medi- cal Sciences (1993). They also question the scientiWc rationale for placebo controls, and suggest equivalency trials, using the best known regimen compared against another: ‘We believe that such equivalency studies of alternative antiretroviral regimens will provide even more useful results than placebo-controlled trials, without the deaths of hundreds of newborns that are inevitable if placebo groups are used’ (Lurie and Wolf, 1997: p. Marcia Angell (1997) takes an even more critical stance, comparing some of the placebo-controlled trials to the infamous Tuskegee syphilis experiment (Anonymous, 1992). She maintains, as do Lurie and Wolf, that researchers have an obligation to provide the controls with the best current treatment, rather than the best locally available one. To do otherwise, she argues, is to adopt a double standard in research, or an ethical relativism that ‘could result in widespread exploita- tion of vulnerable third world populations for research programmes that could not be carried out in the sponsoring countries’ (Angell, 1997: p. Even informed consent is insuYcient protection, she argues, ‘because of the asymmetry of knowledge and authority between researchers and their subjects’ (Angell, 1997: p. The NuYeld Council on Bioethics, in their discussion paper, proposed an interpretation of principle 11–3 of the Helsinki Declaration (World Medical Association, 1996) such that ‘the best proven diagnostic and therapeutic method’ is interpreted as meaning ‘the best locally available diagnostic and therapeutic method’ (NuYeld Council on Bioethics, 1999: p. This sits uncomfortably with Article One of the Declaration, which deWnes the researcher’s duty ‘to remain the protector of the life and health of that person on whom biomedical research is being carried out’. In conclusion, research into the prevention of vertical transmission has engendered a public and acrimonious debate and a schism in the medical profession. Perhaps we are witnessing the clash between an ethic of science Wrmly rooted in the mechanistic-reductionist or modernist paradigm, and an ethic based on a more humanistic, postmodern worldview. It can provide us with useful evidence for the beneWt of interventions, but, in order to achieve this, it eschews individual concerns, needs and relationships. The postmodern ethic, on the other hand, allows for the individual voice to be heard and tolerates uncertainty (Bauman, 1993; Hodgkin, 1996; Laugharne, 1999). One response to the criticisms – a revision of the research guidelines – may lead to a dangerous shift in the ethical require- ments for research, such that research subjects from poor countries could be more readily exploited. Furthermore, the justiWcations do not satisfactorily address the importance of trust, intrinsic to the relationship between the health professional and the woman seeking antenatal care. Amended by the 29th World Medical Assembly, Tokyo, Japan, October 1975; 35th World Medical Assembly, Venice, Italy, October 1983; 41st World Medical Assembly, Hong Kong, September 1989 and the 48th World Medical Assembly, Somerset West, Republic of South Africa, October 1996. It is already possible to test embryos for several conditions at the pre-implanta- tion stage (through pre-embryo biopsy) and to test fetuses for even more conditions during the course of their gestation (through amniocentesis, chorionic villus sampling and umbilical cord blood sampling) (Robertson, 1994: pp. In the near future, however, there will be increased ability to test for mild diseases, late-onset diseases, treatable diseases, propensities for common diseases, and even non-disease characteristics such as longevity, height and body-build (Strong, 1997: p. Although genetic knowledge of this type may strike us as an unalloyed blessing, ethicists worry that such information might fuel parents’ increasing desire for perfect progeny. At most, if their moral views permitted, they could discard a pre-embryo or abort a fetus that tested positive for a relatively small range of genetic maladies, such as Tay–Sachs disease, Down’s syndrome and Fragile X (Robertson, 1996). However, as soon as safe, eVective and beneWcial genetic therapies for embryos and fetuses are developed, parents will have the option of repairing or changing rather than destroying their progeny, an option bound to please those who believe that human life should be protected from the moment of conception on- wards (Mehlman and Botkin, 1998: pp.

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The pain often is relieved by sitting up and bending forward generic 25 mg clomiphene with amex menstrual vs estrous, and is exacerbated by food buy clomiphene 100mg without a prescription menstruation at 8. Patients commonly experience nausea and vomiting that is precipitated by oral intake cheap clomiphene 25mg with visa breast cancer charities of america. They may have low-grade fever (if temperature is >101°F, one should suspect infection) and often are volume depleted because of the vomiting, inability to tolerate oral intake, and because the inflammatory process may cause third spac- ing with sequestration of large volumes of fluid in the peritoneal cavity. The most common test used to diagnose pancreatitis is an elevated serum amylase level. It is released from the inflamed pancreas within hours of the attack and remains elevated for 3 to 4 days. Amylase undergoes renal clearance, and after serum levels decline, its level remains elevated in the urine. Amylase is not specific to the pancreas, however, and can be elevated as a consequence of many other abdominal processes, such as gastrointestinal ischemia with infarction or perforation; even just the vomiting associated with pancreatitis can cause elevated amylase of salivary origin. Elevated serum lipase level, also seen in acute pancreatitis, is more specific than is amylase to pancreatic origin and remains elevated longer than does amylase. Treatment of pancreatitis is mainly supportive and includes “pancreatic rest,” that is, withholding food or liquids by mouth until symptoms subside and adequate narcotic analgesia, usually with meperidine. In patients with severe pancreatitis who sequester large volumes of fluid in their abdomen as pancreatic ascites, sometimes prodigious amounts of parenteral fluid replace- ment are necessary to maintain intravascular volume. Patients with adynamic ileus and abdominal distention or protracted vomiting may benefit from naso- gastric suction. When pain has largely subsided and the patient has bowel sounds, oral clear liquids can be started and the diet advanced as tolerated. Several criteria have been developed in an attempt to identify the 15% to 25% of patients who will have a more complicated course. When three or more of the following criteria are present, a severe course complicated by pan- creatic necrosis can be predicted by Ranson criteria (Table 14–1). The most common cause of early death in patients with pancreatitis is hypovolemic shock, which is multifactorial: third spacing and sequestration of large fluid volumes in the abdomen, as well as increased capillary permeability. Pancreatic complications include a phlegmon, which is a solid mass of inflamed pancreas, often with patchy areas of necrosis. Either necrosis or a phlegmon can become secondarily infected, resulting in pancreatic abscess. Abscesses typically develop 2 to 3 weeks after the onset of illness and should be suspected if there is fever or leukocytosis. Pancreatic necrosis and abscess are the leading causes of death in patients after the first week of illness. A pancreatic pseudo- cyst is a cystic collection of inflammatory fluid and pancreatic secretions, which unlike true cysts do not have an epithelial lining. Most pancreatic pseudocysts resolve spontaneously within 6 weeks, especially if they are smaller than 6 cm. However, if they are causing pain, are large or expanding, or become infected, they usually require drainage. Any of these local complications of pancreatitis should be suspected if persistent pain, fever, abdominal mass, or persistent hyperamylasemia occurs. Gallstones Gallstones usually form as a consequence of precipitation of cholesterol microcrystals in bile. When discovered incidentally, they can be followed without intervention, as only 10% of patients will develop any symptoms related to their stones within 10 years. When patients do develop symptoms because of a stone in the cystic duct or Hartmann pouch, the typical attack of biliary colic usually has a sudden onset, often pre- cipitated by a large or fatty meal, with severe steady pain in the right upper quadrant or epigastrium, lasting between 1 and 4 hours. They may have mild elevations of the alkaline phosphatase level and slight hyperbilirubinemia, but elevations of the bilirubin level over 3 g/dL suggest a common duct stone. The first diagnostic test in a patient with suspected gallstones usually is an ultra- sonogram. The test is noninvasive and very sensitive for detecting stones in the gallbladder as well as intrahepatic or extrahepatic biliary duct dilation. This is apparent ultra- sonographically as gallbladder wall thickening and pericholecystic fluid, and is characterized clinically as a persistent right upper quadrant abdominal pain, with fever and leukocytosis. Cultures of bile in the gallbladder often yield enteric flora such as Escherichia coli and Klebsiella. The positive test shows visualization of the liver by the isotope, but nonvisualization of the gallbladder may indicate an obstructed cystic duct. Treatment of acute cholecystitis usually involves making the patient npo (nil per os), intravenous fluids and antibiotics, and early cholecystectomy within 48 to 72 hours. Another complication of gallstones is cholangitis, which occurs when there is intermittent obstruction of the common bile duct, allowing reflux of bacteria up the biliary tree, followed by development of purulent infection behind the obstruction. After 3 months she is noted to have severe right upper quadrant pain, fever to 102°F, and nausea. This patient with fever, right upper quadrant pain, and a history of gallstones likely has acute cholecystitis. A pancreatic pseudocyst has a clinical presentation of abdominal pain and mass and persistent hyperamylasemia in a patient with prior pancreatitis. Clinical Pearls ➤ The most common causes of acute pancreatitis in the United States are alcohol consumption, gallstones, and hypertriglyceridemia. Cholecystectomy is per- formed for patients with symptoms of biliary colic or for those with com- plications. Initial management of acute pancreatitis: critical issues during the first 72 hours. Case 15 A 72-year-old man is brought to the emergency room after fainting while in church. His wife, who witnessed the episode, reports that he was uncon- scious for approximately 5 minutes. This has never happened to him before, but his wife does report that for the last several months he has had to curtail activi- ties, such as mowing the lawn, because he becomes weak and feels light- headed. His only medical history is osteoarthritis of his knees, for which he takes acetaminophen. He is afebrile, his heart rate is regular at 35 bpm, and his blood pressure is 118/72 mm Hg, which remains unchanged on standing. His chest is clear to auscultation, and his heart rhythm is regular but bradycardic with a nondisplaced apical impulse. Laboratory examination shows normal blood counts, renal function, and serum electrolyte levels, and negative cardiac enzymes. He has experienced decreasing exercise tolerance recently because of weakness and presyncopal symptoms. He should be evaluated for myocardial infarction and structural cardiac abnormalities. If this evaluation is negative, he may simply have conduction system disease as a consequence of aging.

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Treatment: Untreated order 100mg clomiphene breast cancer xbox controller, actinomycosis is ulti- Bronchiectasis is a syndrome discount 100 mg clomiphene otc menopause the musical songs, with many mately fatal generic clomiphene 25 mg on line women's health clinic red deer, but early treatment can result in cure underlying etiologies and associations, that has rates of 90%. Whether patients should be treated for the Classifcation copathogens usually associated with actinomyces is not resolved, but most experts do not recom- A classification system has been devised by mend the administration of additional antibiot- Reed. Patients with actinomycosis have a tendency ing to anatomic and morphologic patterns of to relapse, and prolonged therapy optimizes the airway dilatation as follows: (1) cylindrical bron- likelihood of a cure. However, small trials have chiectasis, in which there is uniform dilatation of shown success with relatively brief courses of the bronchi which are thick walled and extend therapy (6 weeks). In general, the etiolo- areas of constriction and dilatation similar in gies can be categorized as idiopathic, postinfectious, appearance to saphenous varicosities; (3) cystic or the result of an underlying anatomic or systemic bronchiectasis, which is the most severe form and disease. Previously, untreated infection and fluid-filled cysts, with a honeycomb appear- was the leading cause of bronchiectasis, but with ance; and (4) follicular bronchiectasis, which has prompt treatment of infection, it is becoming much extensive lymphoid nodules and follicles within less common. Patients with focal ally occurs after the occurrence of childhood bronchiectasis, which is localized to a segment or pneumonia, measles, pertussis, or adenovirus lobe, should undergo bronchoscopy to evaluate for infection. Treatment with nary function tests may reveal an obstructive multiple antimicrobial agents may lead to the reso- ventilatory defect with hyperinflation and impaired lution of these abnormalities, but prolonged therapy diffusing capacity of the lung for carbon monoxide. Airway hyperresponsiveness has been seen in up There are an increasing number of immune to 40% of patients with bronchiectasis in some deficiencies that have been associated with bron- series. Ciliary disorders are considered to be disease may present with a combined obstructive primary disorders of immune defense because and restrictive ventilatory defect. IgG subclass deficien- ectasis include a mild degree of leukocytosis, cies may be present even with normal total IgG usually without a left shift, an increase in the levels. The classic finding of tram tracks, poses patients to bronchiectasis as a consequence representing thickened dilated bronchial walls, is of a persistent complex immune response to air- best seen on radiographs obtained from a lateral way colonization by Aspergillus. Other findings include hyperinflation and bronchiectasis most commonly involves the central air trapping, increased linear markings, rounded airways, distinguishing it from other types of opacities that represent areas of focal pneumonia, bronchiectasis. Figure 1 shows the char- disease is more common in women and most com- acteristic large bronchi in a patient with Kartagener monly presents in the sixth decade of life. The bacterial floras include Streptococcus pneumoniae and Haemophilus influenzae, which can be treated with trimethoprim-sulfamethoxazole, ampicillin-clavulanate acid, or one of the newer Figure 1. Patients Diferential Diagnosis who experience frequent exacerbations may benefit from a maintenance regimen, but the Given the list of possible etiologies, the follow- evidence for this approach is fairly weak. Strat- ing information should be obtained in the evalua- egies for prophylaxis with low-dose antibiotics tion of patients with suspected bronchiectasis: age range from daily to 1 week of each month. Bronchodilators: Most patients with bronchi- Recurrent fever and hemoptysis are less likely to ectasis have significant airway hyperresponsive- be found in patients with chronic bronchitis. The incidence of Pseudo- has the added potential advantage of the stimula- monas aeruginosa is approximately 31% in patients tion of mucociliary clearance, which is associated with bronchiectasis, but only 2 to 4% in patients with the use of β-adrenergic agents. Bronchiectasis also can be confused ized β-agonist therapy and aerosolized anticho- with interstitial fibrosis, especially in patients with linergic therapy should be tried when there is end-state fibrosis who have a honeycomb-like evidence of reversible airway obstruction. This paren- Antiinflammatory Agents: Although intense chymal honeycomb appearance may mimic the airway inflammation characterizes bronchiec- air-filled cysts of bronchiectasis. It has been shown that inhaled corti- tive and potentially harmful in 300 adult outpa- costeroids can reduce the levels of inflammatory tients with idiopathic bronchiectasis who were in mediators and improve dyspnea and cough. Therapy with inhaled mannitol addition, inhaled corticosteroids appear to reduce may improve impaired mucociliary clearance by sputum volume and lead to improvements in inducing an influx of fluid into the airways and quality of life. Nonsteroidal antiinflammatory agents, such as Exercise Training: The role of pulmonary reha- indomethacin (which is not currently approved bilitation and inspiratory muscle training has only in the United States), have been used in Europe, been investigated in one well-designed trial, but either orally or by inhalation. Leukotriene recep- it has been suggested that rehabilitation increases tor antagonists may be of benefit in patients with exercise tolerance in patients with bronchiectasis. In patients with localized bronchiectasis, surgi- Macrolides suppress inflammation, independent cal removal of the most affected segment or lobe of their antimicrobial action, and have improved may be considered. The major indications for sur- the clinical status and lung function of patients gery include the partial obstruction of a segment in a few small studies of bronchiectasis. Further or lobe as the result of a tumor or the presence of study is needed before they can be recommended a highly resistant organism in the affected area, routinely. Patients require Airway Clearance Techniques: Posturaldrainage significant pulmonary function to withstand sur- and chest physiotherapy are useful to enhance the gery. Alternative treat- ment includes the use of a flutter device, a posi- tive expiratory pressure mask, chest oscillation, Lung Transplantation and humidification of inspired air. This bacte- nancies can be successful, and pulmonary rium is difficult to eradicate as the result of the poor function has not been found to deteriorate after penetration of antibiotics into purulent airway pregnancy. Despite the great advances in the manage- aminoglycosides is increased, and therefore, the ment of this disorder, the majority of the patients dosage has to be adjusted, usually at triple the succumb to respiratory complications. All of the tech- chronic infection because low sodium content is niques require a great deal of time, and treatment required for the effective killing of bacteria in air- compliance can be an issue. The 12 Unusual Lung Infection, Bronchiectasis, and Cystic Fibrosis (Moores) obstructive airway disease is typically only somewhat between the two, it is reasonable to partially reversible because the underlying causes assume that they maybe complementary. Parenteral otics, or dornase alfa because these medications antibiotics are generally administered for 14 to 21 have the potential to induce nonspecific bron- days to reduce the burden of bacteria, to decrease chial constriction. Intensified bronchodilator therapy A metaanalysis of randomized trials of dornase and chest physiotherapy are indicated during alfa has concluded that treatment improves lung the treatment of exacerbations. There is some con- steroids may be used in patients with hyperre- troversy about when to initiate dornase alfa, but active airways, but it has not been systemically most clinicians will consider a trial in patients studied. A combination face via inhalation of a hypertonic substance therapy consisting of an oral quinolone and an might help to clear secretions and restore muco- inhaled aminoglycoside is typically used. The most common tion, and, in one long-term study, with fewer exac- current practice involves the use of nebulized erbations requiring antibiotic therapy. The inhaled route is 7% saline solution) in patients with chronic cough attractive because it allows the delivery of greater and sputum production should be considered. When shown that the long-term use of azithromycin considering potential antiinflammatory strate- (which appears to act primarily as an antiinflam- gies, several key concepts must be kept in mind: matory agent by inhibiting neutrophil migration the inflammatory process is primarily endobron- and elastase production) is associated with chial; it is characterized by persistent neutrophil improved lung function and a reduction in the influx; intracellular signaling pathways are a key number of exacerbations. In high doses, ibuprofen appears to have been developed for other diseases (rheuma- slow the progressive decrease in lung function, toid arthritis, psoriasis, inflammatory bowel dis- particularly in younger patients with a milder ease). In addition, there is some concern that is based on four trials enrolling a total of 287 these agents might overly suppress the inflamma- patients, confirms this finding. Finding ways to interrupt intracel- serum levels, and thus the drug must be individu- lular signaling pathways that lead to increased ally dosed based on measured pharmacokinetics inflammation may also be an effective strategy, but (desired peak plasma concentrations between 50 more understanding of the complex roles these and 100 μg/mL). In addition, this Nontuberculous Mycobacterial Infections: Re- therapy is limited by expense, supply, and the risks cently, there has been a marked increase in the of using plasma-derived products. Some of this isolation of nontuberculous Mycobacterium sp may be overcome in the future with recombinant (primarily Mycobacterium avium intracellulare α1-antitrypsin. Nodular goal: sufficient gene product must be delivered to opacities or a tree-in-bud appearance suggests the primary target cells and it must be incorporated the presence of infection rather than colonization. Diagnosis is confirmed by total serum IgE rest, cough suppression, antibiotics, and correc- levels of 1,000 ng/mL and IgE or IgG specific tion of coagulopathy, if present, are adequate to A fumigatus.

Despite a vast body of ever buy generic clomiphene 25 mg online breast cancer awareness month 2014, much confusion about the most effcient research into specifc dietary problems best 50mg clomiphene menstrual gush, much method to achieve an adequate nutritional of the available literature is confusing because status at the start of pregnancy clomiphene 25mg generic womens health 6 week meal plan, especially if a of lack of standardization of methodologies of nutritional defciency is present. No consensus study, indecision about whether specifc nutri- regarding the defnition and/or understanding ents should be evaluated alone or in combina- of ‘adequate nutrition’ exists, and even less tion, and absence of agreement as to whether uniformity of opinion is present for a defni- the dose should be tested in relation to what tion of ‘optimal nutrition’, even though some a normal person might consume in a 24-hour authorities might suggest that diet alone sup- period or as a megadose that exceeds anything ports health and longevity. The same may be said regarding optimal Beginning with birth, each of us eats foods vitamin supplementation in pregnancy, be it which are usually chosen by individuals who the type or the dose. Table 1 has been prepared have had no formal training in domestic sci- to provide health care professionals a handy ences, dietary technology, or food prepara- guide that they can share with their patients. Mothers and grandmothers sanctioned Not only are the nutrients and their respective food choices determined by local availability, budget, accessibility of refrigeration and com- doses listed, but also cited are the appropri- munity or religious practices that often stretch ate sources of the information. Any meaningful discussion Recommended Defciency effect of supplementation must address three crucial taking a folic acid supplement, taking a multi- intake for on expectant Defciency effect Nutrient pregnant women mother on offspring Source Effect of excess vitamin containing the requisite amount of issues – who to supplement, how to supple- folic acid among other constituents, or eating ment and what to supplement. This enormous effort resulted reasonable if it were possible to test for all in a 27% reduction in the incidence of neu- essential pregnancy-related vitamins, miner- ral tube defects in 1999–2000 compared to Even as recently as 10 years ago, it might fails to stress that it is ineffective and perhaps als and micronutrients in a cost effective and 1995–199624. Such testing rou- ues, but it has not been total, perhaps because vitamins, minerals and micronutrients in a acid only when they are pregnant, because tinely is not available in most hospitals where the fortifcation process was confned to wheat monograph devoted to preconception counsel- 50% of pregnancies are unintended and any the majority of deliveries are conducted. This is not the case for three important folic acid taken after the 28th day following if it were, the unpredictability of pregnancy Hispanic population consistently eat products reasons. Not fortifying corn plementing women of childbearing age is a constant warm temperature for hours before adequate folate supplementation before preg- products may not be the entire reason for the rational means of ensuring that women have consumption, may lose a signifcant, albeit nancy because (1) patients are not routinely smaller response in the American Hispanic adequate levels of essential vitamins, minerals unknown, portion of their expected values tested for folate levels, meaning that those population, but it is signifcant that the largest and micronutrients when they become preg- compared to what would have been present who are defcient are unknown, and (2) many manufacturer of corn tortillas in Mexico has nant. In the long run, such therapy is capable had they been eaten immediately or shortly patients, especially those in their second preg- voluntarily added folate fortifcation (Linda of circumventing the dietary variations that after cooking. Such food is found in cafeterias, nancy or higher, tend to come for their frst Van Horn, personal communication, July 20, exist within populations and between indi- steam lines, hotel buffets, etc. The information cited here contrasts viduals, each of whom may be convinced that exists totally apart from other issues related lowing conception because they believe they with the public health considerations relat- her particular diet is adequate, if for no other to ‘fast foods’ that are eaten shortly after their know the ‘routine’ or, in the case of grandmul- ing to food fortifcation and/or comprehensive reason than it may be prepared by someone preparation. Other problems that affect food tiparas, are burdened with childcare responsi- multivitamin products for pregnant women outside her home and/or at great expense. Moreover, physicians now recognize that provide the internationally recommended great importance, supplementing that is begun light and hormones during the growing period, that folic acid is of beneft throughout the levels of folic acid rather than relying on obtain- before pregnancy can be continued during the the need to pick fruits and vegetables in a pre- remainder of a pregnancy because of cellular ing folate and other essential vitamins, miner- pregnancy by changing to a traditional prena- ripened state for transport to the point of sale, development and synergy with B vitamins. Knowledge of the essential pregnancy- population that are marginalized, living below related requirements for specifc vitamin con- the poverty level, and who seek prenatal care The accumulated literature on vitamins, min- Functional foods stituents has increased exponentially since late in pregnancy. Folate is not the only vita- erals and micronutrients is impressive, to say 1990, and many clinicians have begun to see min that may be defcient in the general popu- the least. Terms that describe the quantity and Functional foods are provided to confer a ‘ben- the value of prescribing a ‘balanced palate’ lation, as shown by a recent national dietary variety of research and opinions might include eft’ to the diet beyond that of simple nutri- ‘staggering’ or ‘daunting’, and therein lies the of components that includes vitamins, min- survey in the United States that sampled tion. The average practitioner has little erals and micronutrients in one pill or cap- women aged 19–49 and showed that 90% had mon foods can be enhanced by several means, time or inclination to read even a small quan- sule. The catch-all term for this type of addi- supplements should be advised only when spe- necessary to anticipate the increased need for evidenced by the heterogeneity of information tives is nutraceutical, which can also be used cifc defciencies are present. This ing the vitamins, minerals and micronutri- Fibers tions, clinicians are unaware of the relative simple concept can and should be part of the ents mentioned below will add nothing to the states of defciency or adequacy of circulating counseling provided to every women of repro- clinical acumen of any health-care professional Fibers are either readily fermentable by colonic levels of vitamins, minerals and micronutri- ductive age when she has a medical encounter who may read this chapter. Simply stated, we believe that mod- ern diets can be defcient in vitamins, minerals ing a ‘mop and sponge effect’ in the colon and obstetric deliveries are not at all equipped to and micronutrients for several reasons – over- assisting in the formation of the fecal contents. In this regard, it is intake level suffcient to meet the nutrient becomes a way of life based on the recognition genetically engineered designer foods, herbal noteworthy that as of early 2009 one of the requirements of nearly all (97–98%) healthy of the inherent defciency of modern diets in products and processed foods such as cere- major worldwide producers of birth control individuals in each age group and sex. It is important to pills is adding folic acid fortifcation to each set when there are insuffcient scientifc data note that this defnition applies to all catego- pill. Indeed, it has been sug- occurs by the 28th day of embryogen- antioxidant ingredients, and a stimulant func- and yogurt; a low intake of meat; and a mod- gested that without supplementation, esis (42 days after the onset of the last tional food or ‘pharmafood’ and fbers. What has not Probiotics tive age are single and often employed, special pregnancy have been associated with been appreciated until recently is that efforts must be made as part of the counseling reduced risks for offspring with heart folate defciencies must be addressed A probiotic is defned as a ‘live microbial food process when pregnancy is desired to inform before the woman becomes pregnant, defects, especially ventricular septal supplement’ that benefcially affects the host patients that reliance on modern fast foods is because many women do not receive defects and conotruncal defects (e. Lactic acid not a means to enhance nutrition and that eat- medical care until after the 28th day of tetralogy of Fallot and transposition bacteria, particularly Lactobacillus spp. Most research in this cannot be corrected in time to prevent trolled intervention trials are lacking, biotics at the time of this writing and can be area has been confned to older individuals, neural tube defects [which] may have secondary analysis of a Hungarian combined with food products such as cereals, many of whom were residing in institutional already occurred. Of perhaps greater inter- synergistically toward maintenance of a desir- est to obstetricians/gynecologists is able microbial population in the intestine. The most common include ous preterm delivery between 20 and ties of vegetables, legumes, fruits and cereals with the exception of liver, is not a anencephaly and spina bifda, which 28 weeks, a fnding that remained (largely unrefned); a moderate-to-high intake good source of folate. Medicine followed in 1998, advising To what extent this disparity exists and available metabolically as active that all women capable of becom- because of the propensity of Hispanic iodine26,27. Here the recommended sider a daily intake of 100μg of iodine This change is considered of great 36 reasonable to presume that other fac- per day for adults as being suffcient dose is 4mg per day (ten times the importance because numerous inves- tors may be working concomitantly. Certainly it was known Most of these anemias had their onset • The numbers cited above relating to mined that 15% of women aged 15–40 to obstetricians practicing by the before conception, and the presence absorption cloud the clinical picture. This number is adverse effects of anemia is copious, • Defciency during pregnancy may be as such was often cited as the cause of great importance when advising with low birth weights, premature accompanied by catastrophic conse- of gastrointestinal discomfort that patients regarding a prenatal supple- delivery and low neonatal iron stores quences, including spontaneous abor- ranged from pain and cramps to diar- ment that contains iron, because being prominent. Newborns may exhibit goi- that many women, especially multipa- of that which can be absorbed and ter, mental retardation and cretinism, ras, are all too happy to deposit their which may be the cause of gastroin- Supplementation the most extreme form of neurologi- prescriptions for iron products in the testinal disturbances. The waste basket when leaving the clinic brain is particularly sensitive to def- • Iron status is often measured by • Given the circumstances described or doctor’s consultation. The recommendations • Effect of excess – when the recom- most common defciency, and a poten- markers that are better indicators of of the Institution of Medicine are mended intake is vastly exceeded, tial cause of anemia in pregnancy if its iron stores, however, especially the 51 the excess intake of iodine may rarely complex. Its ability to con- total serum iron binding capacity, result in goiter, thyrotoxic crisis and Obstetricians and Gynecologists rec- vert between the ferrous (Fe2+) and with levels of more than 450μg/dl hyperthyroidism. The need for increased 47 ments such as these make a simple tute of Medicine considers the safe • Dietary iron consists of heme and iron is based on the increases in the proposition unnecessarily complex upper limit for iodine intake to be non-heme (inorganic) forms. Estimations of patients who come for antenatal care poultry, whereas plant-based foods not clear but illustrate the complexity the amount of iron that needs to be with the presumption that they will (vegetables, fruits and grains) are the of attempting to defne upper limits absorbed in the second and third tri- be given vitamin and iron supple- sources of non-heme iron, although of intake that are appropriate for all mester are 4–5mg/day and 6–7mg/ mentation. These needs are par- prenatal supplements contain ratio- from broccoli and cabbage, and low tially addressed by existing iron stores nal amounts of iron, it seems reason- from legumes, rice and maize). Early symptoms and newborn neurodevelopment and the selenium levels in food (plant or nant and lactating women is 1200mg include vomiting, nausea, hypoten- infammation. Supplementation sion and respiratory diffculties; later, cal to fetal and infant central nervous across regions with disparate levels of is the only way to achieve this, and multiple organ failure or central ner- system growth and development53,54. During the last trimester, the become a signifcant part of food forti- sume only foods grown locally in low • Effect of excess – the upper intake fetus accrues about 50–70mg/day of fcation, with food companies around selenium regions. Only high-selenium yeast has cod liver oil, are also high in vitamin defciency and malformed infants has manifest in illness; rather, it weakens been shown to lower cancer incidence A content. Three diseases has the greatest amount of provitamin • European crop survey data indicate • Toxicity – case reports of offspring are associated with severe selenium A activity. Vitamin A is essential for selenium levels in British and Euro- with anomalies after mothers took defciency in children: Keshan disease vision, reproduction, immunity, skin pean wheats to be generally 10–50 high levels of vitamin A75,76 have led that results in an enlarged heart with and epithelial integrity, and the trans- times lower than in American or to some concern about high doses poor function, Kashin-Beck disease duction of light into neural signals in Canadian wheats. It is especially critical during from such wheat, a staple grain for sistent pattern of anomalies has myxedematous endemic cretinism periods wherein cells rapidly prolifer- example, would fail to help consum- been observed74, caution has been that results in mental retardation.