Symptoms of menopause

Symptoms of menopause

It is important to realize that the symptoms of
oestrogen defi ciency, loosely termed menopausal
symptoms, may begin long before the actual cessation
of menstruation, which, as noted above, defmes the
menopause itself. These symptoms are often triggered
by a relative fall in circulating E2 and hence may afflict
the patient b fo re the absolute level of circulating
E2 reaches the levels of the fully developed postmenopause
at Symptoms
Physical
• Tiredness
• Hot flushes
• Night sweats
• Insomnia
• Vaginal dryness
• Urinary freQiuency

Psychological
• Mood swings
• Anxiety
• Loss of short-term memory
• Lack of concentration
• Loss of self-confidence
• Depression

Vaginal dryness is a vitally important symptom of
menopause, not least because it is frequently missed.
Some patients find it difficult to give a sexual history
and thus a gentle, courteous but full enquiry should
be made regarding the presence of dryness and asso ciated
dyspareunia. The latter can lead to significant
disharmony between partners in a relationship. The
vaginal skin is dependent on oestrogen for the depth
and lubrication of its squamous epithelium and, with
loss of plasma oestrogen, the skin becomes thin and
poorly moisturized.

The physical symptoms of menopause are partnered
by a set of psychological symptoms that can
be equally distressing and disabling. The degree to
which these symptoms are due to a lack of oestrogen
per se or to chronic sleep deprivation is not clear.
In addition, the perimenopausal years are often
marked by life events such as divorce, departure of
children, death of partner or parents and other stressful
occurrences that may contribute to the overall
psychological picture. Intrinsic personality type may
also exert an influence, with the symptoms being
more marked among those with a tendency to anxiety
and low self-esteem. There does not, however, appear
to be a true increase in formal psychiatric disorders
at this time.

Overall, it should be stressed that the severity,
duration and nature of menopausal symptoms are
highly variable. Symptoms may be absent, they may
be fleeting and mild, or they may be severe and continue
for years. The duty of the clinician is to assess
the global effect of the symptom complex presented
and to decide whether or not an exogenous replacement
of the lost oestrogen is likely to result in a
significant reduction in the symptom load.

Cataracts

Cataracts

Definition
The lens of the eye is normally transparent. A
cataract is a condition in which the lens of the eye
becomes cloudy or opaque. This cloudiness can impair
vision and may lead to eventual blindness.

Description
The human eye has several parts. The outer layer of
the eyeball consists of a transparent dome-shaped cornea
and an opaque, white sclera. The cornea and sclera help
protect the eye. The next layer includes the iris, pupil,
and ciliary body. The iris is the colored part of the eye
and the pupil is the small, dark, round hole in the center
of the iris. The pupil is primarily responsible for allowing
light into the eye. The ciliary body contains muscles
that help the eye focus. The lens, which lies behind the
pupil and iris, is covered by a cellophane-like capsule. It
is normally transparent, elliptical in shape, and somewhat
elastic. Due to this elasticity, the lens can focus on
both near and far objects. The lens is attached to the ciliary
body by fibers (zonules of Zinn). Muscles in the ciliary
body act on the zonules, which then change the
shape of the lens. This process is called accommodation—
the lens focuses images to help make vision clear.
As people age, the lens hardens and changes shape less
easily. As a result, accommodation becomes more difficult,
making it harder to see things up close. This normal
aging condition, called presbyopia, generally occurs
around age 40 and continues until about age 65.
Individuals with this condition generally need reading
glasses.
The lens is made up of approximately 35% protein
and 65% water. As people age, degenerative changes in
the lens’s proteins occur. Changes in the proteins, water
content, enzymes, and other chemicals are some of the
reasons for the formation of a cataract.
The major areas of the lens are the nucleus, the cortex,
and the capsule. The nucleus is in the center of the
lens, the cortex surrounds the nucleus, and the capsule is
the outer layer. Opacities can occur in any area of the
lens, and cataracts can be classified according to their
location (nuclear, cortical, or posterior subcapular
cataracts). The density and location of the cataract determines
the amount of vision affected. If the cataract forms
in the area of the lens directly behind the pupil, vision
may be significantly impaired. A cataract that occurs on
the outer edges or side of the lens causes less visual
impairment.
Cataracts in the elderly are so common that they are
thought to be a normal part of aging. Cataracts affect
about 50% of individuals between the ages of 52-64,
while at least 70% of those 70 and older are affected.
Cataracts associated with aging (senile or age-related
cataracts) are usually bilateral (occur in both eyes) with
asymmetric progression (different rates of progression).
Initially, cataracts may not affect vision. If the cataract
remains small or at the periphery of the lens, the visual
changes may be minor.
Cataracts are much less common in younger people.
Congenital cataracts are rare in newborns. When they do
occur, they may be due to genetic defects or an infection
or disease in the mother during pregnancy. Traumatic
cataracts may develop after a foreign body or trauma
injures the lens or the eye. Systemic illnesses, such as
diabetes, also may result in cataracts. Cataracts can occur
secondary to other eye diseases—for example, uveitis or
glaucoma. Such cataracts are called complicated
cataracts. Toxic cataracts result from chemical toxicity,
such as steroid use. Cataracts also can result from exposure
to the sun’s ultraviolet (UV) rays.

Causes and symptoms
Recent studies have investigated the effect of nutrition
on cataract formation. The results have been mixed,
with some studies finding that there is a connection
between nutrition and cataract formation and other studies
finding none. Much interest has been focused on the use of
antioxidant supplements as a protection against cataracts.
Antioxidants, such as vitamins A, C, E, and beta-carotene,
help the body neutralize oxygen-free radicals.
Smoking and alcohol intake, however, have been
implicated in cataract formation, as have the use of oral
corticosteriods and antihypertensive agents. Some studies
have determined that a diet high in fat increases the
likelihood of cataract formation, while an increase in
foods rich in antioxidants reduces the incidence. More
research is needed to determine the precise role played by
diet, smoking, alcohol consumption, and antioxidants in
the formation of cataracts.
Some unrelated physical conditions, such as diabetes
mellitus, also may contribute to cataracts. Eye
injuries and sun exposure also are causative factors.
There are several common symptoms of cataracts:
• gradual, painless onset of blurry, filmy, or fuzzy vision
• poor central vision
• frequent changes in eyeglass prescriptions
• changes in color vision
Cataracts
• increased glare from lights, especially oncoming headlights
when driving at night
• “second sight” improvement in near vision (no longer
needing reading glasses)
• poor vision in sunlight
• presence of a milky whiteness in the pupil as the
cataract progresses

Diagnosis
Ophthalmologists and optometrists detect and monitor
cataract growth and prescribe prescription lenses
for visual deficits. Ophthalmologist perform cataract
extraction.
Cataract diagnosis begins with a complete eye exam.
The ophthalmic assistant, technician, or nurse gathers
information to determine the progression of the vision
loss. It is unusual for cataracts to cause rapid vision loss,
but sometimes patients believe the vision problem is
acute because vision in the better eye has only recently
been compromised. Patient history includes a review of
refractive history, previous ocular disease, ambylopia,
eye surgery, and trauma. Ophthalmic personnel also
question patients about difficulties driving, reading, and
performing daily activities, and record any medication
the patient currently uses.
The ocular exam determines the severity of the
cataract and assesses other factors that might contribute
to the potential for good vision after surgery. The exam
includes measurement of visual acuity under both low
and high illumination, biomicroscopy with pupillary
dilation, stereoscopic fundus examination with pupillary
dilation, assessment of ocular motility and binocularity,
visual fields, evaluation of pupillary responses, refraction,
and measurement of intraocular pressure (IOP).

Treatment
No treatment may be necessary for cataracts that
cause no symptoms or that cause only minor visual
changes. It is important for an ophthalmologist or
optometrist to continue to monitor and assess the cataract
during regular office visits. Increased strength in prescription
eyeglasses or contact lenses may be diagnostic
and beneficial.
Cataract surgery—the only option for patients
whose cataracts interfere with vision to the extent that
their daily activities are affected—is the most frequently
performed surgery in the United States. It generally
improves vision in more than 90% of patients. Most
cataracts are removed before the lens is completely
opaque or mature. This is done to minimize the impact of
the cataract on the patient’s daily life and also to decrease
the risk of other eye complications. Sometimes cataracts
need to be removed so the surgeon can examine the back
of the eye more carefully. This is important in patients
with diseases that may affect the eye. If cataracts are
present in both eyes, surgery is performed on one eye at
a time. The first eye heals before the second cataract is
removed, sometimes as soon as the following week. A
final eyeglass prescription is usually given about four to
six weeks after surgery. Patients will still need reading
glasses. The overall health of the patient must be considered
in making the decision to have undergo cataract surgery.
However, age alone need not preclude effective surgical
treatment of cataracts, and people in their 90s can
have successful return of vision after cataract surgery.
Surgery to remove cataracts is generally an outpatient
procedure. A local anesthetic is used, and some
newer techniques take only minutes to complete.
Removal of the cloudy lens can be accomplished with
one of the three types of cataract surgery available:
• Extracapsular cataract extraction. In this type of
cataract extraction, the lens and the front portion of the
capsule are removed. The back part of the capsule
remains in place.
• Extracapsular cataract extraction by phacoemulsification.
This type of extracapsular extraction requires only
a very small incision, resulting in faster healing.
Ultrasonic vibration is applied to the lens to break it up
into very small pieces, and the ophthalmologist then
aspirates the pieces out of the eye with suction. As of
2001, this is the most commonly performed type of
cataract surgery.
• Intracapsular cataract extraction. The lens and the
entire capsule are removed. This method carries an
increased risk for detachment of the retina and swelling
after surgery, and, as a result, it is rarely used.
442 GALE ENCYCLOPEDIA OF NURSING AND ALLIED HEALTH
A replacement lens is inserted at the time of the surgery.
A plastic artificial lens called an intraocular lens
(IOL) is placed in the remaining posterior lens capsule of
the eye. When the intracapsular extraction method is
used, an IOL may be clipped onto the iris. Contact lenses
and cataract glasses (aphakic lenses) are prescribed if
an IOL cannot be inserted due to complications. A folding
IOL is used with the phacoemulsification procedure
to allow it to pass through the small incision.
Antibiotic drops to prevent infection and steroids to
reduce inflammation are prescribed after surgery. An eye
shield or glasses protect the eye from injury while it
heals. During the night, an eye shield is worn. The patient
returns to the doctor the day after surgery for assessment,
with several follow-up visits over the next two months to
monitor the healing process. Return visits at three and six
months are optional.

Prognosis
The cataract extraction success rate is very high with
a good prognosis. A visual acuity of 20/40 or better is
expected as a result of cataract extraction. If an extracapsular
cataract extraction was performed, a secondary
cataract may develop in the remaining back portion of the
capsule. This can occur one to two years after surgery.
YAG capsulotomy is most often used for this type of
cataract. YAG stands for yttrium aluminum garnet, the
name of the laser used for this procedure. This is a painless
outpatient procedure and requires no incision. The
laser beam makes a small opening in the remaining back
part of the capsule, allowing light through.
Complications occur in a very small percentage (3-
5%) of surgical cataract extractions. Possible complications
include infections, corneal edema (swelling),
diplopia, bleeding, retinal detachment, iris prolapse or
vitreous in the wound, intraocular lens dislocation, and
Cataracts

KEY TERMS
Glaucoma—Disease of the eye characterized by
increased pressure of the fluid inside the eye.
Untreated, glaucoma can lead to blindness.
Ultraviolet radiation (UV)—Invisible light rays
that may be responsible for sunburns, skin cancers,
and cataract formation.
Uveitis—Inflammation of the uvea. The uvea is a
continuous layer of tissue which consists of the
iris, the ciliary body, and the choroid. The uvea
lies between the retina and sclera.
the onset of glaucoma. Some problems may occur one to
two days, or even several weeks, after surgery. Follow-up
examinations should check the patient for haziness or
redness in the eye, decrease in vision, nausea, and pain.

Health care team roles
Skilled ophthalmic technicians and assistants record
the patient history and perform many of the preliminary
tests. Depending on skill level, these ophthalmic assistants
may perform measurement of visual acuity under
both low and high illumination, biomicroscopy with
pupillary dilation, assessment of ocular motility and
binocularity, visual fields, evaluation of pupillary
responses to rule out afferent pupillary defects, refraction,
and measurement of intraocular pressure (IOP).
Before the surgery, nurses and assistants also prepare
the operating room (OR). Many ophthalmologists now
have their own ambulatory surgery centers (ASCs) where
skilled technicians and ophthalmic nurses play a critical
role in preparing the OR and patients for the surgery.
Ophthalmic nurses also assist the ophthalmologist during
surgery and discuss outcomes with patients postoperatively.

Patient education
When a cataract is found, the patient should be
informed, even if surgery is not immediately indicated.
The optometrist or ophthalmologist should discuss the
different treatment options, as well as the risks and benefits
of surgery with the patient.

Prevention
The eyes should be protected from UV radiation by
wearing glasses with a special coating. Dark lenses alone
are not sufficient, but the lenses must be coated to filter
out UV light (specifically, UV-A and UV-B). Antioxidants
also may help prevent cataracts by reducing free radicals
that can damage lens proteins. A healthy diet rich in
sources of antioxidants, including citrus fruits, sweet
potatoes, carrots, green leafy vegetables, and/or vitamin
supplements, may be beneficial. When taking certain
medications, such as steroids, more frequent eye exams
may be necessary. Patients should also be told not to
smoke.

Abortion in the Twentieth Century

Abortion in the Twentieth Century

The first country to legalize abortion in the twentieth century was the Soviet Union. In
November 1920, after Vladimir Lenin, the first head of the USSR, insisted that no woman
should be forced to bear a child against her will Abortion in the Twentieth Century 5
and that women should be guaranteed the right of deciding pregnancy for themselves, abortion
was made legal. A second motivating factor, however, was the government’s effort to eliminate
the medical havoc of widespread criminal abortion. The Soviets estimated that up to 50
percent of women became infected during the course of undergoing an illegal abortion and
perhaps as many as 4 percent of them died. Interestingly, the Malthusian belief in the dangers
of overpopulation that was so prevalent in the west was not an issue in the new Soviet state
because Karl Marx, and for that matter Lenin, regarded such concerns as a unique problem of
capitalism. Once legalized, the number of legal abortions rose rapidly, whereas illegal abortions
dropped drastically. American observers of the Soviet experience reported almost an assembly
line procedure, with abortions in a Moscow hospital being done every eight minutes by a
two-person team. What was most upsetting to the observers, however, was the lack of any
counseling or the availability of any contraceptive materials.

Without warning and for no apparent reason, in 1936 the Soviet government reversed itself
and banned legalized abortion. This coincided with a general effort to abandon many of the
human rights victories originally established by the early Bolsheviks such as easy divorce, progressive education, and avant-garde schools of music and literature. The ban also indicated the increasing power of Soviet premier Joseph Stalin and it was not until after his death that the Soviet state in 1955 again legalized abortion. Again the official explanation was to eliminate the
harm caused by illegal abortions and to allow women to decide for themselves the question of
motherhood. Although contraceptives were more available in the Soviet Union than they
were earlier, there was no concentrated contraceptive information until after the collapse of
the Soviet Union. Abortion, however, since its legalization, has remained widespread.

Following the Soviet example, other Eastern bloc nations followed suit. Bulgaria, Hungary,
and Poland legalized abortion in 1956, Rumania legalized it in 1957, and Czechoslovakia started
with unrestricted abortions but tightened its controls in 1962.Yugoslavia, not in the bloc but
influenced by Soviet examples, established modified controls over abortion in 1960. East Germany was the last to legalize it but one reason for the delay is that it had the most effective contraceptive educational and dissemination system among the Communist countries. When the
Soviet Union collapsed, there were efforts to criminalize abortions, particularly in Poland,
but generally such efforts proved unsuccessful in the long run.

It was the threat of population growth, combined with the devastation resulting from
Japan’s defeat in World War II, that led the Japanese Diet (parliament) to enact in May 1948
the Eugenic Protection Law. The original law legalized abortion only for women whose health
might be impaired from the “physical or economic viewpoint,” but these laws were soon
extended to allow abortion at the woman’s request. Abortion became the standard method
of birth control in Japan, with the result that the Japanese birthrate, 34.3 per 1,000 in 1947, had
dropped to 16.9 by 1961. Like the Soviet Union, the Japanese paid little attention to contraception alternatives even though Margaret Sanger had been invited to Japan as early as
1922.The government, which opposed the invitation but eventually allowed her to enter, was
then dominated by a militarist bloc and proponents of territorial and population expansion,
who opposed the efforts of various women’s groups to encourage the use of contraceptives.
With the government still in opposition, Sanger’s initial effort in Japan to popularize
birth control was a failure. Sanger was again invited in 1950 by a revived Birth Control Association but her initial invitation was blocked by General Douglas MacArthur under pressure
from the Catholic Women’s Club of Tokyo. After MacArthur’s removal from command, Sanger
made a triumphal return to the country. The favored method of family planning, however,
remained abortion.

In Europe, the first country to legalize abortion was Iceland in 1934. Sweden followed in
1938, Denmark in 1939, Finland in 1950, and Norway in 1960, although the actual Norwegian
practice of abortion generally followed that of the other Scandinavian countries even before the law was changed.Various modifications were made in the laws of all the countries, but all of them have a rather formalized procedure for approving abortions, and it is known that those women
denied approval often get illegal ones anyway.

In Great Britain, the early advocates of birth control were antiabortion, although a number of
spokespersons for legalized abortion began to appear in the 1920s. Their numbers grew large
enough by 1936 to found the Abortion Law Reform Association. A turning point in British
public opinion about abortion was a 1938 legal case involving a London surgeon,Aleck Bourne.
Bourne was convinced that it was good medical practice for a physician to perform an abortion
on a woman under certain circumstances but he wanted to make certain the courts agreed. He
tested his beliefs by giving an abortion to a fourteen-year-old girl who had been raped by soldiers and who had been referred to him by the Abortion Law Reform Association. When the
operation was completed, he notified the police, was arrested, and went to trial.The case attracted much attention and Bourne received support from not only a significant portion of the medical community but from important individuals and groups from all segments of society. The
jury agreed and acquitted him on the grounds that the operation had been necessary to preserve
the life of the woman who otherwise, based on psychiatric testimony, might have suffered a physical or mental trauma. Other court cases strengthened the Bourne decision and
Canada and other Commonwealth nations subsequently passed laws justifying abortion if it
was necessary to preserve the mental health of a patient, as well as for physical or health reasons.

In the United States, even when abortion was outlawed, therapeutic abortions were permitted
when in the physician’s opinion continued pregnancy was dangerous to the mother’s life. Decisions in such cases depended on both the individual physicians and the medical communities
in which the operation took place. The number of such abortions began to grow in the 1950s
and 1960s as many physicians took into consideration the emotional health of the woman as
well as her physical problems. Still, the overwhelming number of abortions were illegal
ones, and in the early 1960s minimal estimates were that at least between 400,000 and 640,000 illegal abortions took place every year. The growing ability to lessen by the use of antibiotics the danger of infections was a major factor in changing attitudes about abortion in the medical community and probably made the profession more willing to extend the definition of what constituted therapeutic abortions. The difficulty was that such procedures were more likely to be limited to the well-to-do, who often had a relationship with their private physician, and this
left most of the poor and most needy excluded.

The first move for change came from the legal rather than the medical community, with the publication of the Model Penal Code adopted by the American Law Institute in the 1950s. The proposals were modest, providing for termination of pregnancy when the physical or mental health of the mother was greatly impaired; when the child might be born with a grave physical or mental defect; or when pregnancy resulted from rape, incest, or other felonious intercourse, including illicit intercourse with a girl under the age of sixteen.

Public interest focused on abortion laws in 1962 with the case of Sherri Finkbine, a
Phoenix, Arizona, mother of four, who had taken the tranquilizer thalidomide during the first
few months of her fifth pregnancy. Because the drug had not been approved by the Food and
Drug Administration (FDA), it had not been marketed in the United States. Finkbine’s husband,
however, had returned from Europe with a bottle of thalidomide, which still contained
some pills he had taken, which she used. Two months later the news of the deformities that
the pill was causing in European children—notably stunted or missing arms and legs—was
made public. Finkbine panicked, fearful that her child would be deformed, something with
which she believed she could not cope. She consulted her physician, who estimated that the
chances of her infant being born deformed were at least 50 percent. He then arranged to admit
her to the hospital for a therapeutic abortion. The story reached the newspapers through a
friend of Finkbine’s, and the news of a potential thalidomide baby in the United States received
national publicity. Fearful of publicity about an abortion being performed by its staff, the hospital
canceled the abortion. The distraught Finkbines flew to Los Angeles, planning to travel
to Japan for the abortion, but the Japanese consulate, also afraid of negative publicity,
refused them a visa. The couple then flew to Sweden, where Sherri had the abortion. The
fetus was found to be deformed.

The publicity led to a greater focus on the abortion issue and gave publicity to groups
encouraging a change. The American Civil Liberties Union went on record as regarding abortion
as part of a woman’s right to have control of her own body. In California, the Committee for
Therapeutic Abortion, a coalition of civil libertarians, women’s organizations, physicians, and
liberal religious groups, was established in 1965. The next year the National Organization for
Women was established, with reproductive rights as one of its major concerns.The National
Association for the Repeal of Abortion Laws was established in 1968.

Beginning in 1967, several states modified their antiabortion laws, using all or part of the
8 Abortion in the Twentieth Century proposals of the American Law Institute. By 1970
thirteen states had passed such legislation and others were considering it. The advocates for
legal reform also worked through the courts, so that by 1972 federal court decisions had liberalized abortion privileges in three jurisdictions. In 1973, the case of Roe v.Wade (one of several abortion cases being appealed) was decided by the U.S. Supreme Court, which ruled that abortions were a constitutional right and laws prohibiting them were null and void, although the rights of states to regulate abortions under certain conditions were recognized.The anonymous Jane Roe, who brought the suit in Texas, was later identified as Norma McCorvey. The decision did not help her because the court procedure took so long that she had already delivered her baby and put it up for adoption by the time the Supreme Court rendered its decision. In its ruling, the Court held that for the first three months of pregnancy the matter of abortion was to be decided by the woman and her physician. During the remaining six months the states were permitted to regulate the procedures used in order to ensure reasonable standards of care. Only in the last ten weeks of pregnancy, however, could the state ban abortion unless it was necessary to preserve the life of the mother. In spite of various legal challenges that have emphasized the power of the states to regulate abortions, this is essentially the law that remains today.

Most of the opposition coalesced under the collective title of “right to life.” The radical
fringe of these groups bombed abortion clinics or chained themselves to clinic doors to block
entrances, and even murdered physicians who performed abortions. More mainstream members worked through the political process to weaken the right to abortion by passing restrictive state laws requiring the husband’s consent, requiring parental consent for minors, cutting off public funding, and/or adding procedural requirements such as waiting periods.

The ideological and political make up of the Supreme Court as well as other federal courts
changed during the administration of Ronald Reagan (1981–1989), who insisted on an
antiabortion litmus test for his court appointees. President George H.W. Bush (1989–1993) followed the same path but not quite as zealously. Bill Clinton’s ascendancy to the presidency in
1993 marked the abandonment of such a policy, although the battle continues as it did for any
method of birth control. George W. Bush, elected in the year 2000, is openly antiabortion, and
has talked about appointing one of the antiabortion justices as Chief Justice.

Increasingly, countries in Latin America, Africa, and Asia have allowed abortion. China
uses it extensively; India, less so. Abortion still remains a controversial issue in many parts of
the world.

When performed under aseptic conditions by a competent professional, abortion is a relatively safe procedure.When performed by inexperienced people or under unhygienic conditions, as so often happens in the case of illegal abortions, it is much more dangerous, not only in terms of maternal deaths, but in terms of long-term complications.Techniques vary with the stage of fetal development at which an abortion is sought. It is easiest during the early stages of pregnancy and both more complicated and dangerous in later stages.

Early abortion, sometimes called by its advocates postcoital contraception or menstrual regulation, can be brought about by several methods that rely on hormones or mechanical
techniques. Various combinations of the hormones estrogen and progesterone (components
of the oral contraceptive) are capable of terminating a pregnancy or bringing on the menses,
although this has not been widely publicized. The FDA has been reluctant to formally approve
any hormones for this purpose, more from political considerations than safety concerns, but
in recent years has become more public about it, and in the year 2000 approved RU-486. There
are many people who consider any contraceptive administered after an unprotected act of
intercourse to be an abortifacient, and given this assumption, there are many clinics that do not
Abortion in the Twentieth Century 9 prescribe any postcoital contraceptives, whereas
others may limit their use to rape victims.

For contraceptive pills such as Orval, with 50 micrograms of estrogen and 0.5 milligrams of progestin, a total of four tablets should be taken in divided doses, an initial two, and then two twelve hours later. The series must start within seventy-two hours of the incident of unprotected intercourse, but preferably within twenty-four hours. Other pills vary in the doses. A postcoital insertion of a copper intrauterine device (IUD) has also proved effective in regulating menses by preventing implantation of the fertilized ovum in the uterus. IUDs that release hormones would have the same effect. All these procedures can be called menstrual regulators rather than abortifacients because no egg has been implanted.

Another method of bringing about an early abortion is menstrual extraction. This involves
the insertion of a Karman cannula (tube) into the uterus and the removal of menstrual blood
and tissue. A syringe or a suction machine is used to extract the uterine lining. This method
is also regarded as a menstrual regulator and is often prescribed for a woman whose period is
late; in fact, some women have used it to shorten the length of a menstrual period. No pregnancy
test is required but casual use of the technique is not recommended because of the
risk of hemorrhage and infection. The method was originally developed by Sir James Simpson
in the nineteenth century to regulate menstruation and has been improved upon by later generations of physicians, most of whom refused to regard it as an abortion technique even
though it was used for that purpose. It was not until the late 1950s, when a Chinese medical
journal referred to it as a way of performing abortions, that Western medical journals were
willing to discuss this use.

A traditional abortion technique, known by the ancient Greeks, is dilation and curettage (D&C). It is also used for a variety of purposes other than abortion, including taking biopsies to detect malignancies, dealing with prolonged bleeding from the uterus, and removing unexpelled placenta after childbirth. It involves dilation of the cervix and cleaning out the uterus with a curette. In unskilled hands it can lead to infection. Usually laminaria (cervical tampons that swell to three or five times their original diameter when placed in a moist environment) are used to dilate the cervix.

Midtrimester abortions (between the fourth and sixth months) are more difficult. Although
D&C and vacuum aspirations are used early in this three-month period, both become increasingly risky and difficult as pregnancy advances. For most such late abortions a hypertonic saline solution is used.This method was first described in 1939 by a Rumanian physician but it was not used in the United States or in Western Europe until the 1960s. It involves the instillation of hypertonic saline (a 20 percent sodium chloride solution) in the amniotic sac or into the extraovular space (between the amniotic sac and uterus). A second method is the administration of prostaglandins, which encourage uterine contractions and are administered similarly to the hypertonic saline solution. Prostaglandins can also be given intravenously, intramuscularly, intravaginally, orally, or rectally. Third-quarter abortions require major surgical intervention and should generally be avoided unless the life of the mother is threatened.

Signs and Symptoms of A Molar Pregnancy

Signs and symptoms of a molar pregnancy

1. Normal first trimester symptoms
2. Persistent nausea and vomiting
3. Bleeding by 12th week (continuous or intermittent, usually light)
4. "Large for dates" are typical, although about 25 percent may be "small for dates"
5. No fetal heart tones or fetal movement
6. Hypertension may become a problem in the second trimester
7. Shortness of breath (late, life threatening indication of an embolism)
8. Enlarged, tender ovaries (ovarian cysts)
9. Passage of "grape-like" vesicles with bleeding

Diagnosis of a molar pregnancy is made by ultrasound and by elevated beta hCG levels. There is a rare risk (two percent) of choriocarcinoma (cancer) following molar pregnancy. Benign tumor formation may also occur.

Treatment involves evacuation, usually with suction curettage, of the vesicles within the uterus. Lab studies might include serial beta hCG levels, blood clotting studies, liver and thyroid profiles, hemoglobin, and chest X-ray.

Beta hCG levels are drawn every one to two weeks until resolved and then they may be done on a regular schedule for the year following the loss.

Because the risk of cancer needs to be fully evaluated, effective contraception should be used for one year following the pregnancy. Regular visits for a physical and pelvic exams are made until the uterus and ovaries are back to normal. Thereafter, they are generally done every three months for the next year.

In subsequent pregnancies, the woman may be at higher risk of another molar pregnancy, so she is followed closely with serial hCG levels and ultrasound.

Experiencing a molar pregnancy is extremely stressful for the woman, her partner and family. Not many people understand the physiology of such a pregnancy. It is generally best to tell loved ones that a miscarriage has occurred and that special followup lab work is necessary. When the pregnancy itself has been "ambiguous" and the life of the mother has been at risk, it may be harder to understand and disclose all of the details.

Exercise and PMS

Exercise is often recommended as a treatment for PMS, but there is no published study demonstrates its efficacy as the sole intervention. Timonen and Procope surveyed than 700 female college students and reported that premenstrual complaints were less frequent among those who participated in sports. Prior and Vigna compared the effects of exercise on premenstrual symptoms in sedentary women and runners. Increased exercise was associated with improvements in fluid and breast related symptoms, based on daily symptoms reports, as well as premenstrual dysphoria up to 6 months after initiation of an exercise program. No changes in control subjects were observed. In the strongest study design, Lemon evaluated the effect of aerobic training in 32 women with prospectively confirmed PMS. Women were randomly assigned to either a high-intensity aerobic training group or a low-intensity control group. Although the high-intensity aerobic group reported greater reductions, both groups exhibited significantly fewer symptoms as compared with baseline. Further controlled studies are needed to clarify whether exercise can alleviate or mitigate physiologic or psychological symptoms of PMS.

Source:
Debra A. Krummel, Penny M. Kris-Etherthon. Nutrition in Women's Health. Aspen Publishers, 1996.

Ectopic Pregnancy

Ectopic Pregnancy

Ectopic pregnancy occurs whenever the blastocyst implants anywhere except in the endometrium lining the uterine cavity. Possible sites for ectopic pregnancy include the cervix, fallopian tubes, ovaries, and abdomen. Predisposing factors to ectopic pregnancy are given in this section. For a woman with a suspected ectopic pregnancy, the midwife should draw blood for a quantitative human chorionic gonadotropin, obtain an ultrasound, and notify the consulting physician. Early diagnosis and referral to the physician are critical. If a tubal pregnancy can be diagnosed before rupture, microsurgery or medical management with methotrexate is more likely to save the fallopian tube.

Source:

Helen Varney. Varney’s Midwifery. Jones & Bartlett Publishers, 1997.

Postpartum Depression

Postpartum Depression

Postpartum depression starts later, is more intense and devastating, and lasts longer than postpartum after-baby blues. It may start anytime during the first year postpartum. The mother gradually slips deeper and deeper into depression, becomes increasingly incapable functioning, and thinks angry and hurtful thoughts about her baby, which she suppresses because she’s “not supposed to think this way.” She becomes lonely and isolated and feels she has lost control. She is truly suffering.

Beck has identified 11 themes and developed a checklist of 11 symptoms of postpartum depression a mother can experience, to be used by a health care professional in discussion with a mother:

1. Lack of ability to concentrate; feeling “in a fog”
2. Loss of previous interest and goals; feeling empty.
3. Unbearable loneliness; feeling that no one understands.
4. Insecurity and need to be mothered herself.
5. Obsessive thinking about being a bad mother.
6. Lack of positive emotions-perceives herself as going through motions like a robot.
7. Loss of self from fear that normalcy in her life is irretrievable.
8. Loss of control of her emotions.
9. Anxiety attacks; feeling that she is on the edge of insanity.
10. Guilt and fear at thoughts of harming infant.
11. Thoughts of death to end this living nightmare.

Postpartum depression should be differentiated from postpartum psychosis, which is a very confused state of extreme highs and lows, agitation, seeing and hearing things that others don’t (including voices that may “order” the persons to do things she normally would not do), and frightening thoughts of harming herself of her baby. A mother with these symptoms needs immediate psychiatric help. Postpartum depression also must be differentiated from postpartum thyroiditis with its symptoms of extreme fatigue and weight loss, or later, weight gain. Differentiation is difficult because both postpartum depression and postpartum thyroiditis present with overwhelming fatigue, which affects the mother’s activities of daily living and her capacity for taking care of her baby. A thyroid work-up is indicated when a mother’s depression is prolonged, her weight does not stabilize, the onset of her fatigue was rapid, and fatigue is present without physical exertion.

It is most helpful in the midwife’s approach to a mother with postpartum depression to acknowledge what she is experiencing and to tell her it’s ok to express what she may think are socially unacceptable negative feelings. Connecting her with support groups may be useful. Mild forms of depression may be helped with plans for coping such as getting out of the house, doing something for herself each day, having contact with and communicating with adults, talking with a friend about what she feels, doing some form of exercise, and paying attention to nutrition.

Source:

Helen Varney. Varney’s Midwifery. Jones & Bartlett Publishers, 1997.