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CLOSE THIS BOOKClinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)
Chapter 9 - Other conditions
VIEW THE DOCUMENTCardiac failure
VIEW THE DOCUMENTHypertension
VIEW THE DOCUMENTAcute glomerulonephritis
VIEW THE DOCUMENTNephrotic syndrome
VIEW THE DOCUMENTLithiasis
VIEW THE DOCUMENTPyelonephritis
VIEW THE DOCUMENTProstatitis
VIEW THE DOCUMENTSexually transmitted diseases (STD)
VIEW THE DOCUMENTVaginitis
VIEW THE DOCUMENTEndometritis and Salpingitis
VIEW THE DOCUMENTPV bleeding
VIEW THE DOCUMENTToothache: different syndromes
VIEW THE DOCUMENTDental infections
VIEW THE DOCUMENTEndemic goitre

Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)

Chapter 9 - Other conditions

Cardiac failure

Syndrome characterized by the failure of the myocardium to maintain an adequate cardiac output. Often called congestive cardiac failure, or CCF.

Clinical features

- Exertional and paroxysmal nocturnal dyspnea (pulmonary edema).
- Hepatomegaly (tender liver on palpation).
- Ankle edema.
- Tachycardia with gallop rhythm.
- Basal crepitations on auscultation of both lung fields.

There are 3 forms of cardiac failure:

- Left ventricular failure

· Dyspnea: either exertional, recumbent (as in paroxysmal nocturnal dyspnea), or fulminant (acute pulmonary edema).

· Crepitations (rales) in the lung bases on auscultation (may be absent in infants); sometimes pleural effusion.

· Tachycardia, gallop rhythm.

- Right ventricular failure

· Edema: especially of the ankles and lower legs.
· large, tender, sometimes pulsatile liver.
· Raised jugular venous pressure.

- Biventricular failure: combination of right and left sided signs.

Symptomatic treatment (hospital)

- Half-sitting position, oxygen if available.
- Exclude salt from diet.
- Drain any pleural effusion.
- Diuretics:
· Acute pulmonary edema
furosemide (IV)

Adult: 20 to 40 mg/IV, repeated as needed
Child: 1 mg/kg/IV, repeated as needed

Compensated cardiac failure
furosemide (PO)

Adult: 20 mg/ d divided in 2 doses
Child: 1 to 2 mg/kg/d

Furosemide therapy depletes potassium and therefore the patient should be supplemented:
potassium chloride: 1 g/day, 5 days out of 7

If furosemide is ineffective, use an aldosterone antagonist:
spironolactone (PO)

Adult: 100-200 mg/day in single dose
Child: 3 mg/kg/day

· If furosemide or spironolactone are not immediately effective in acute pulmonary edema, two measures can reduce the load on the failing myocardium:

- Rotating tourniquets

- Venesection: bleed 200 to 400 ml; ensure first that significant anemia is not contributing to the cardiac failure.

- For left ventricular failure only

· In urgent situations (e.g. acute failure) digoxin (IV)

Adult:

loading: 0.25 mg/injection, 3-4 injections in first 24 hours


maintenance: 0.25 mg/24 hours in 1 injection

Child:

loading: 0.010 mg/kg/injection, 3-4 injections in first 24 hours


maintenance: 0.010 mg/kg/24 hours in 1 injection

In non urgent situations digoxin (PO)

Adult:

loading: 0.5 -1 mg/d divided in 2-3 doses x 2-3 days


maintenance: 0.25 mg/ d, for 5 days out of 7

Child:

loading: 0.015 mg/kg/dose: 3-4 doses/24 hours x 2-3 days


maintenance: 0.015 mg/kg/d in a single dose, for 5 days out of 7

- Treatment should be supervised: weight, dyspnea.

- Complications of treatment are bradycardia, arrhythmias and embolism.

- Pneumonia sometimes precipitates or complicates CCF. Treat with appropriate antibiotics.

Always seek a treatable cause.

The regimens below will usually be supplemented by symptomatic therapy of the CCF.

- Anemia: if severe enough to cause CCF may need transfusion. Great care is needed because of the danger of fluid overload: usually furosemide is given at the same time as any transfusion.

- Beri-beri: think of this, especially in SE Asia thiamine (vitamin B1)

Adult:200 mg IM or IV/day
Child:50 to 100 mg IM or IV

Continue with at least 200 mg / day PO for several weeks.

- Endocarditis
penicillin G (IV): 100,000 IU/kg
+ gentamicin (IM): 3 mg/kg/day

- Chagas'disease.

Acute rheumatic fever: myocarditis may lead to CCF in the acute stage.
penicillin G or PPF (IM): 100,000 IU/kg/d x 10 days.
prednisolone (PO): 2 mg/kg/d x 3-5 days, then decreasing dose regimen over 7 to 10 days.

Prophylaxis:
benzathine penicillin (IM): 1.2 - 2.4 MIU every 2 to 4 weeks.
< 15 years: 1.2 MIU every 2 weeks
> 15 years: 2.4 MIU every 2 weeks
for several months if possible.

Hypertension

- Before diagnosing hypertension, the BP must be checked several times with the subject resting.

- Drug therapy should only be instuted for BP consistently above 160/90 mm Hg (or 140/9Ofor pregnant women).

- Therapy must be closely supervised, otherwise side effects can be serious.

Treatment

ESSENTIAL HYPERTENSION (dispensary)

No evident cause, in a non-pregnant subject.

- Low-salt diet: follow-up one week later.

- If BP still > 160/90: drug therapy.
hydrochlorthiazide (PO): 50 mg/ d, best taken in the morning.
Give potassium supplement (e.g. advise bananas in diet).

- If no improvement after one week give in addition:
methyldopa (PO): commence with 250 mg/d divided in 2-3 doses, total dosage to be attended progressively 750 to 1,500 mg/d divided in 3 doses (upper limit).
or
hydralazine (PO): 100 mg/d divided in 3-4 doses, if necessary can be increased till 200 mg/day

- Alternative:
propanolol(PO): 40 mg/d (start with a low dose and increase slowly as needed. Do not let PR drop below 50-60 /min).

HYPERTENSION OF PREGNANCY

Along with albuminuria and edema it is part of the syndrome of pre-eclampsia. This is a condition of late pregnancy and is associated with severe complications: eclampsia, abruptio placentae and premature labour.

(dispensary)

- Rest, normal diet (do not restrict salt), encourage good protein intake.

- Sedation if necessary:
diazepam (PO): 15 mg/d divided in 3 doses

- Observe regularly: BP, weight, albuminuria, edema, fetal heart sounds and movements, fundal height.

- If no improvement after one week:
hydralazine(PO): 100 mg/d divided in 3-4 doses (up to double this if needed)
or
methyldopa (PO): 750 to 1500 mg/ d divided in 3 doses

(hospital)

Severe cases (very high BP, edema, headache, nausea, convulsions), i.e. preeclampsia:
diazepam (IV): 40 mg in 500 ml 5 % glucose infusion (to avoid risk of convulsions and lower BP).

Definitive treatment: delivery, vaginal if possible.

- Eclampsia
hydralazine(ampoule de 20 mg/ml, 1 ml) in infusion, protect from light, 4 ampoules of 20 mg in 500 ml 5 % glucose, delivered at 30 drops/minute, until normal BP achieved. Monitor rest of drip according to BP level.
Convulsions: diazepam in infusion (see above).
Nursing
Obstetrical management: eventual caesarian.

Acute glomerulonephritis

- An auto-immune inflammahon of the renal tubules.

- Most often occurring as a complicahon of an otherwise benign shreptococcal infection. Usually manifests itself 1 to 5 weeks following an episode of pharyngitis or impetigo.

- Affects mainly children over 3 years of age and adults.

Clinical features

- Proteinuria and hematuria.
- Hypertension, sometimes becoming malignant (encephalopathy).
- Edema.
- Occasionally cardiac failure.

Treatment (dispensary - hospital)

- Bed rest during the early period.

- Low salt diet.

- Furosemide (PO) if necessary: see above.

- Treat the hypertension.

- Treatment against the streptococci:

· Acute phase: as for strep pharyngitis
· Prophylaxis against relapse: as for rheumatic fever

Nephrotic syndrome

- A syndrome that in its uncomplicated form comprises:

· proteinuria (> 3 gram/24 hours),
· hypoalbuminemia (< 30 gram /litre),
· edema.

- These simple forms generally resolve completely. If complications are present (hematuria, hypertension, or renal failure), the disease has a poorer prognosis.

Treatment (dispensary - hospital)

- Rest.
- High protein diet.
- Restricted salt and water intake.
- Diuretics:
furosemide (PO)

Adult:160 mg/d divided in 3-4 doses
Child:4 mg/kg/d divided in 3-4 doses

Adapt dosage according to clinical response.

For nephrotic syndrome in children, consider
prednisone or prednisolone (PO): 2 mg/kg/day x 5 days, then reduce dose progressively

Cystitis

- Infection of the bladder and urethra, most often due to Escherichia coli.

- Very frequent in women.

Clinical features

- Painful micturition (burning, scalding).
- Polyuria, nocturia.
- Urine cloudy and malodorous (sometimes hematuria).
- No fever.

Treatment (dispensary)

- Increase fluid intake: 3 to 4 litres/day, to flush out the bladder.

- Immediate antibiotic regimens (at the latest 3 days of beginning attack; ensure no surgical operations or urinary infections during the last 3 months): cotrimoxazole (PO): 1.6 g of SMX in a single dose.

- Standard antibiotic regimen:
ampicillin (PO): 2-3 g/d divided in 3 doses x 5-7 days
or
cotrimoxazole (PO): 1.6 g of SMX/d divided in 2 doses x 3 days

- Exceptions

· pregnant women:
ampicillin (PO): 2 g/ d divided in 3 doses x 10 days

· If signs of ascending infection (fever, chills, pain), treat as pyelonephritis.

- Recurrent cystitis: think of schistosomiasis, urinary tuberculosis, a bladder stone or gonorrhoea.

Otherwise, give antibiotic therapy for 10 days.

Lithiasis

The formation of stones (calculi) in the urinary tract, which may cause varying degrees of obstruction.

Clinical features

- Renal colic: intense lumbar or pelvic pain, which may be either intermittent or constant.
- Hematuria, gravel in the urine, passing of a calculus.
- Microscopy: many red cells, sometimes some pus cells.
- Secondary infection is common: presents as cystitis or pyelonephritis.

Treatment (dispensary)

- Encourage copious oral fluids: at least 3 to 4 litres /day.

- Analgesia:
noramidopyrine (PO) (provided drug if prescribed list of the country): 1.5 g/d divided in 3 doses x 3 days
+ butylhyoscine (PO): 30-60 mg/d divided in 3 doses x 3 days

- Antispasmodic: noramidopyrine (IV) (provided drug if prescribed list of the country):500 mg as required
+ atropine (IM): 1 mg as required

- Secondary infections: treat appropriately.

Pyelonephritis

Urinary tract infection involving the renal parenchyma, most often due to Escherichia coli.
Clinical features

- High fever (this may be the only sign in neonates).
- Chills, loin pain, dysuria, cloudy and sometimes bloody urine.
- Microscopy: abundant pus cells, red cells and bacteria on gram stain.

Treatment (dispensary - hospital)

- Treat the fever.
- Encourage abundant oral fluids (3 to 4 litres/day).
- cotrimoxazole(PO)

Adult: 1.6 g of SMX/d divided in 2 doses x 10 days
Child: 40 mg of SMX/kg/d divided in 2 doses x 10 days

- If very ill, or if cotrimoxazole ineffective after 3-4 days:
ampicllin (IV): 100 mg/kg/d divided in 4 injections for several days, then change to oral treatment (total:10 days)
+ gentamicin (IM): 3 mg/kg/d divided in 2-3 injections x 5-7 days.

Prostatitis

- Acute infection of the prostate gland.
- Usually due to gram negative bacteria.

Clinical features

- Scalding pain on urinating, polyuria, low grade fever and perineal pain.
- Tender on PR examination.
- Urine: pus cells, with occasionnal red cells.

Treatment (dispensary)

- Difficult to effect cure so often becomes a chronic infection.

- Encourage abundant oral fluids (3 to 4 litres/day). cotrimoxazole (PO): 1.6 g of SMX/d divided in 2 doses x 2 weeks to 1 month.

- If this ineffective:
ampicillin (PO): 2 g/d divided in 3 doses x 10 days

Sexually transmitted diseases (STD)

ATTENTION
All patients suffering from sexually transmitted disease are likely candidates for HIV (i.e. practising non protected sexual intercourse).

Urethritis

Sexually transmitted infection of the urethra, most often gonococcal or chlamydial (the two may co-exist), occasional due to Trichomonas vaginalis or stanphylococci.

Clinical features

- Incubation period 3 to 8 days.

- Often asymptomatic in females.

- Morning discharge from urethra with dysuria in males.

- Microscopic examination of fresh specimen of urethral discharge using gram stain (intracellular gram - diplococci). Always check partner(s).

Treatment (dispensary)

Whenever possible do a gram stain of the urethral discharge before starting treatment.

GONOCOCCUS (GRAM-DIPLOCOCCI ON GRAM STAIN)

- cotrimoxazole(PO): 4 g of SMX/d in 1 dose x 3 days (= 10 tab 480 mg x 1 x 3 d)
- or chloramphenicol(PO): 2.5 g/d in 1 dose x 2 days (= 10 tab 250 mg x 1 x 2 d)

of if available and recommended in regulations:

- spectinomycine IM: 2 g in a single dose
- or kanamycine IM: 2 g in a single dose

Then:

- tetracycline (PO): 1.5-2 g/d divided in 3-4 doses x 7 days
(except in pregnant or breast feeding women)

- or doxycycline (PO): 200 mg/d divided in 2 doses x 7 days (except in pregnant or breast feeding women)

- or erythromycin (PO): 1.5-2 g/d divided in 3-4 doses x 7 days

In region where gonococcal resistance is still rare:

- PPF IM: 4.8 MIU in a single dose (half given into each buttock)
- or amoxicillin (PO): 3 g in a single dose
plus:

- probenecid (PO): 1 g in a single dose
probenecid is contraindicated in pregnant or breast feeding women.
then:

- tetracycline, or doxycycline, or erythromycin (see above).

TRICHOMONAS VAGINALIS

- metronidazole(PO): 2 g in a single dose (= 8 tab 250 mg)

- or metronidazol(PO): 750 mg/d divided in 3 doses x 7 days (= 1 tab 250 mg x 3 x 7 d) Metronidazole is contraindicated in the first trimester of pregnancy.

NO ORGANISM FOUND ON LABORATORY TESTING

Treat as a chlamydial infection:

- tetracycline (PO): 1.5-2 g/d divided in 3-4 doses x 10 days

- or doxycycline(PO): 200 mg/d divided in 2 doses x 10 days

- or, like for pregnant or breast feeding women: erythromycin(PO): 1.5-2 g/d divided in 3-4 doses x 10 days

If no laboratory available, use one of the gonorrhaea treatment regimens above.

Always trace and treat all sexual contacts. Advise sexual abstinence or use barrier methods of contraception during treatment.

Evolution

If neglected, Ask of re-infection and serious complications: prostatitis, salpingitis, pelvic peritonitis, septicaemia, arthritis and eventually infertility in females.

Syphilis

A sexually transmitted disease due to Treponema pallidum.

Clinical features

Primary syphilis:

- Incubation period of 3 weeks (range 10 to 50 days).

- Single painless ulcer on the genitals with rounded, well-defined edge and indurated base. Sometimes there is inguinal adenopathy.

- Diagnosis often missed in women.

- Diagnosis by examining serous discharge from ulcer under dark-ground microscopy and by serology (VDRL, TPHA), Giemsa stain not advised because of other saprophyte treponemes in genito-perineal region.

- If untreated will evolve through secondary and tertiary stages.

Treatment (dispensary)

- benzathine penicillin: 2.4 MIU IM, repeated after 2 weeks.

- Trace and treat all sexual contacts.

- If allergic to penicillin:
tetracycline or erythromycin (PO): 2 g/d divided in 34 doses x 14 days

Prognosis

- If promptly treated, cure is complete.
- Untreated: evolution through secondary and tertiary stages.

Chancroid

Sexually transmitted disease of which the causative agent is the Ducrey bacillus, Haemophilus ducreyi.

Clinical features

- Incubation period of 3 to 5 days (range 1 to 15 days).

- Lone or multiple ulcers on the genitals (deep, painful, with a soft irregular base).

- Tender inguinal lymphadenopathy. Fistula formation may follow.

- Diagnosis is by smear from the ulcer (May- Grun-Wald-Giemsa stain).

Treatment (dispensary)

- Cotrimoxazole(PO): 1.6 g of SMX/d divided in 2 doses x 10-15 days
or erythromycin: 2 g/d divided in 3-4 doses x 10-15 days

- Trace and treat all sexual contacts.

Note: the ulcer may show sign of healing at the end of a week's treatment. If not suspect:

1. diagnostic error or tablets incorrectly or not taken;
2. drug resistance;
3. association with syphilis or AIDS.

Lymphogranuloma venereum

A sexually transmitted disease, often abbreviated LGV, also known as Nicholas-Favre disease, and caused by Chlamydia trachomatis, especially in men, may be latent in women.

Clinical features

- Incubation period of 1 to 6 weeks.

- Small genital ulcer, not always present.

- Inguinal lymphadenopathy (nodes suppurate, ulcerate and communicate, forming fistulae).

Treatment (dispensary)

- tetracycline (PO): 1.5-2 g/d divided in 4 doses x 21 days
- Trace and treat all sexual contacts.
- Alternatives:

· erythromycin: 1.5-2 g/d divided in 34 doses x 21 days
· cotrimoxazole: 1.6 g of SMX/d divided in 2 doses x 21 days

- Never incise or drain lymph nodes as this retards healing. If necessary, aspirate fluctuant glands with a syringe through overlying healthy skin.

Donovanosis or granuloma ingninale

Sexually transmitted disease also known as granuloma inguinale and due to Calymmatobacterium granulomatis. Much less common than LGV, it occurs in southern India, tropical and subtropical Africa, Papua New Guinea, South America and the Caribbean.
Non sexual contamination can occur (young children).

Clinical features

- Chronic painless granulomatous lesion of genitals.
- May also be inguinal or perineal.
- Develops over years if not treated.

Treatment (dispensary)

- Local disinfection.
tetracycline(PO): 2 g/d divided in 3-4 doses
or ampiclllin (PO): 2-3 g/d divided in 3-4 doses
or cotrimoxazole(PO): 1600 mg of SMX/d divided in 2 doses
Therapy should continue until lesions healed (if not relapse occurs). Alternative therapy. Minimal course:14 days.

- WHO recommends the systematic use of tetracycline with:
streptomycine IM: 1 g/d in single dose x 14 days

If this fails:
chloramphenicol(PO): 1.5 g/d divided in 3 doses
+ gentamicin (IM): 3 mg/kg/d divided in 3 doses
for 3 weeks

Genital herpes

Sexually transmitted disease caused by herpes simplex virus

Clinical features

- Multiple vesicles which evolve into tiny painful ulcers of the genitals.

- Attacks recur periodically.

- A benign condition except when it affects a pregnant women at delivery when there is a risk of disseminated infection in the neonate.

Treatment (dispensary)

- Reassure.

- Local disinfection with chlorhexidine-cetrimide solution or chloramine solution (preparation: see table 25).

- Apply gentian violet solution.

- Can relapse.

Condyloma acuminatum

Raised wartlike lesions, found on the vulva or under the foreskin or on the skin of the anus.
Benign growth (papillomas).
Sexually transmitted viral infection.
Can deteriorate when atypical or pigmented condyloma, biopsy.

Clinical picture

- Incubation period is several months.

- Single condylomatous lesion at beginning, which multiplies and grows and can become infected. Diagnosis is often missed in women.

Treatment

- Difficult to cure (frequent relapses).

- Previous local disinfection.

- Cautiously apply podophylline 10 or 20 % only to the growth. Leave it for 4 hours, then clean. Repeat every day for 3 to 4 days/week x 1.5 month maximum.

- Untimely and excessive treatment can cause painful ulcerations.

- Podophylline can be replaced by trichloracetic acid 80-90 % in same regime. Powder with talc or bicarbonate to remove excess acid.

- Podophylline and trichloracetic acid are contraindicated for cervical condylomas for which cryotherapy, electrocoagulation or surgical ablation should be used.

Vaginitis

Infection of the vaginal mucosa caused by various pathogens: Candida albicans, Trichomonas vaginalis, Neisseria gonorrhaeae, Chlamydia trachomatis and others.

Clinical features

- White offensive vaginal discharge with itching, burning or discomfort.

- Diagnosis by direct smear (trichomoniasis, candidiasis) and gram stain (gonococcus).

Treatment (dispensary)

- Candida albicans

· Douche with an alkaline solution: sodium bicarbonate or lemon juice or diluted vinegar (one teaspoon of vinegar in 1 liter of water).
Or an antiseptic solution (chlorhexidine-cetrimide)

· Apply gentian violet solution for 14 days.

· Use nystatin vaginal pessaries: insert 1 each night x 10 days.

- Trichomoniasis

· metronidazole (PO): 2 g in single dose (gynaecological tablets are inefflcient)

· In case of failure, metronidazole(PO): 1 g/d divided in 2 doses x 7 days

- Gonorrhaea and chlamydia
Treat as for gonococcal urethritis.

- Non-specific vaginitis

· Douche several times daily with: chloramine solution diluted 1 in 2 (see table 25) or povidone iodine (10 % concentrated solution) diluted 1 in 20 for a few days

· If no improvement after a few days: cotrimoxazole(PO): 1.6 g of SMX/d divided in 2 doses x 7 days Pregnant women: ampicillin(PO): 2 g/d divided in 3 doses x 7 days

- Treat all sexual partners.

Endometritis and Salpingitis

A bacterial infection of the uterus (endometritis) or Fallopian tubes (salpingitis), sometimes causing pelvic peritonitis and septicemia. Often termed PID, the condition includes infections of both puerperal and venereal origins.

Clinical features

- Fever, abdominal pain, offensive discharge and sometimes bleeding.
- Vaginal exam: enlarged tender uterus.
- Speculum: pus emerging from the cervical os.
- Signs of peritonitis on abdominal palpation.

Etiological treatmetnt

PUERPERAL SEPSIS (hospital)

Endometritis following delivery, miscarriage or abortion.

- Post-partum sepsis with no evident cause, retained placenta with secondary infection: usually streptococcal or gram negative.

· ampicillin (IV): 100 mg/kg/24 hours divided in 4 injections/24 hours

· Observe progress closely, if no improvement: gentamicin (IM): 3 mg/kg/24 hours divided in 3 injections/24 hours

· Manual evacuation of the retained placenta. Wait until defervescence under antibiotics.

- Abortion (induced) (sometimes Clostridium perfringens).
penicillin G (IV): 100 000 IU/kg/24 hours divided in 4 injections x 10 days
+ metronidazole (PO): 1.5 g/d divided in 3 doses x 10 days.

VENEREAL INFECTIONS (hospital)

- Same clinical picture as above, or else an isolated salpingitis, either gonococcal or chlamydial.

- Laboratory confirmation is preferable.

- Give IV antibiotics:
Peniclllin G (IV): 100,000 IU/kg/24 hours divided in 4 injections/24 hours x 3 to 5 days, then continue with once daily PPF(or procain penicilline)
or
ampicillin (IV): 100 mg/kg divided in 4 injections/24 hours

- For chlamydia:

tetracycline (PO): 2 g/d divided in 3 doses x 10 days.
or
erythromycin (PO): 50 mg/d divided in 3 doses x 10 day

- If in doubt, give:

penicillin G with tetracycline
or
ampicillin or erythromycin

IN CASES OF PUERPERAL SEPSIS AND VENEREAL INFECTION WITH NO BACTERIAL CONFIRMATION

- In the absence of bacteriological confirmation and if there are signs of peritonitis, give:
ampicillin (IV): 100 mg/kg/24 hours divided in 3 injections x at least 10 days
+ gentamicin (JM): 3 mg/kg/24 hours divided in 2 injections x 8 days
+ metronidazole (PO): 1.5 g/d divided in 3 doses x 10 days

- At the end of the treatment, continue with:
tetracycline (PO): 1.5 g/d divided in 3 doses x 10 days

- In cases of an abscess in the pouch of Douglas, pyosalpinx or diffuse peritonitis, hospitalizefor surgical treatment.

PV bleeding

- Vaginal bleeding other than during menstruation. The origin may be vaginal, cervical or uterine.

- If chronic, anemia may occur.

- If hemorrhage is profuse, shock is likely. Nurse patient supine, observe pulse and BP, establish IV line, check hematocrit and restore blood volume.

Bleeding in the non-pregnant patient

PRE-PUBERTAL GIRLS (dispensary)

- Eliminate:

· trauma or foreign body,
· vaginal tumour (rare).

- Treat appropriately: remove foreign body and suture traumatic wounds.

WOMEN OF CHILDBEARING AGE (dispensary)

Diagnosis depends on clinical examination of the vagina with/without speculum.

- Cervicitis or ectropion: inflamed cervix, sometimes associated with vaginitis. Exclude cervical cancer, take a smear for bacteriological diagnosis and treat as for vaginitis.

- Cervical cancer: surgery if available.

- Normal cervix with enlarged uterus: exclude pregnancy.

- If uterine fibroids:
norethisterone (PO): 5 to 10 mg/day from the 10th till the 25th day of the menstrual cycle for 3 cycles, then adapt according to response.
Surgery if no improvement.

- Normal cervix, normal uterus with adnexial mass: exclude ectopic pregnancy. Chronic: ovarian cyst, hydrosalpinx. Surgical referral.

- Normal examination:

· With an oral contraceptive or *Depo-Provera bleeding can be due to poor compliance or poor tolerance.

· Uterine polyp.

· Functional menorrhagia or endometrial hypertrophy, consider: norethisterone (PO): 5 to 10 mg/day from the 10th till the 25th day of the menstrual (PO): 5-10 mg/day from day 15-25 of menstrual cycle

· Schistosomiasis: check for eggs of S. haematobium in the urine

MENOPAUSAL WOMEN

- Endometrial carcinoma (uterus sometimes enlarged). Hysterectomy if surgical facilities available.

N.B.:
In all of the above situations anemia must be prevented or corrected with: ferrous sulphate + folic acid (PO): 6 tab/d divided in 3 doses x 1-2 months.

Bleeding during pregnancy

FIRST TRIMESTER (hospital)

Miscarriage (spontaneous aborhon): contractions and bleeding.

- Establish IV line, restore volume if shocked, observe pulse and BP.

- 3 stages:

· Cervix closed (threatened miscarriage). Bed rest, monitor vital signs.

· Cervix open, sometimes with expulsion of products (inevitable abortion). If does not progress, curettage may be necessary (digital after 2 months gestation).

· Uterus involuted, products expelled (completed abortion).

Curettage if suspicion of retained products of conception.

- Antibiotic prophylaxis:
PPF(or procain penicillin) (IM): 4 MIU/d x at least 5 days.

Induced abortion (patient may deny it)

- Manage as for miscarriage plus broad-spectrum antibiotic cover:
ampicyllin (IV): 100 mg/kg/d divided in 4 injections x 7 days
or
chloramphenicol (IV): 75 mg/kg/d divided in 4 injections x 7 days.

- If a clostridium perfringens infection is suspected, treat with:
penicillin G (lV): 100,000 IU/kg/ /24 hours divided in 4 injections x 10 days
+ medronidazole(PO): 1500 mg/d divided in 3 doses x 10 days

Ectopic pregnancy: bleeding, pelvic pain, malaise and shock.

- The uterus is of normal size or a little enlarged.
- PV exam: marked adnexial tenderness and in pouch of Douglas.
- There is a danger of rupture leading to hemoperitoneum, exsanguination and death.
- IV line, resuscitation, transfusion as needed.
- Urgent laparotomy.

Hydatidiform mole (relatively common in North Africa and Asia)

- Shortly after conception there is bleeding and often severe nausea and vomiting, and the uterus is larger than expected.

- Grape-like vesicles may be expelled.

- IV line, suction or digital curettage (not instrumental, as danger of perforation).

- Prolonged follow-up because of risk of choriocarcinome: pregnancy tests or HCG levels if available, initially every fortnight, then monthly for at least a year. Provide effective contraception during this period.

Third trimester

(hospital)

Premature labour: scanty bleeding, contractions before term, cervix may be open and effaced, uterus non-tender, examination otherwise normal

- Bed rest.

- salbutamol infusion: 3 mg (6 amp of 0.5 mg/ml) in glucose or normal saline over 24 hours. Monitor the rate of infusion, pulse and BP, and foetal heart rate.

- Continue therapy for 24 hours after the contractions cease.

(hospital)

Placenta praevia: profuse painless hemorrhage

- Patient supine, establish IV line. Monitor pulse, BP, blood loss and foetal heart rate. Transfusion as needed (consider HIV).

- If in premature labour, treat accordingly (see above).

- If full term and in labour and partial placenta praevia only, rupture membranes and attempt vaginal delivery.

- If bleeding intractable, or if complete placenta praevia, deliver by caesarian section.

Abruptio placentae: also known as accidental hemorrhage or retro-placental hematoma.

It is caused by premature separation of a normally inserted placenta. Frequent antecedents are pre-eclampsia or trauma (road accident or a beating). Bleeding may only be minimally evident vaginally and the amount seen bears little relation to actual blood loss. There is severe continuous abdominal pain, shock and a hard uterus. The fetus is often dead. Disseminated intravascular coagulation may occur as a complication.

- Establish IV line, transfuse to maintain stable vital signs.

- Live fetus perform a caesarian section.

- If vital signs are stable and labour is advanced or there is a dead fetus, vaginal delivery should be attempted.
Rupture membranes.
Give analgesia:
pentazocine (IM): 30 mg
+ butylhyoscine (IV) as needed.
Induction and augmentation:
oxytocin: 5 IU in 500 ml 5% glucose, adapt rate of infusion in terms of response.
Forceps or vacuum extraction may be necessary.
Beware of post-partum hemorrhage.

(hospital)

Post-partum hemorrhage (PPH)

- After all deliveries the pulse, BP and blood loss should be monitored. Normal loss is less than 500 ml.

- If there is PPH (> 500 ml).

- Establish IV line. Restore blood volume as necessary with plasma volume expanders or whole blood.

- Careful examination to determine cause of hemorrhage:

· Retained placental tissue.

· Uterine atony: if uterus not contracted, exclude retained placenta (requires manual removal).

· Lacerations: perineum, vagina, cervix (inspect the cervix by drawing it gently forward with the help of a scrubbed assistant using three sponge forceps).

· Coagulopathy.

- Treatment:

· Manual exploration of the uterine cavity whenever there is the slightest doubt (anesthesia, full aseptic technique) followed by: methylergometrine: 0.2 mg IV thence IM 2 or 3 times/day
+ ampiclllin prophylaxis.

· Suture any bleeding lacerations.

· Replace blood losses by transfusion where available. If coagulopathy is suspected, transfuse with fresh blood.

· Follow-up with ferrous sulphate + folic acid for 2 months.

Late PPH: subacute bleeding accompanied by fever is probably due to a retained placenta with secondary infection.

-Treat appropriately.

Toothache: different syndromes

Toothache is a common complaint. The causes are multiple but there are seven identifiable syndromes:

- Pain induced by cold (rather than heat), by acidic foods, by sugar, and relieved once the stimulus is removed, is caused by dental caries.

- Pain spontaneous, intermittent and radiating, is caused by a nerve exposed by advanced caries.

- Pain induced by cold, heat, acidic foods, sugar and persisting for several minutes after suppression of the stimulus is due to pulpitis.

- Pain which is spontaneous, continuous, intense, throbbing, exacerbated by heat and percussion on the affected tooth, not relieved by ordinary analgesics, is caused by a dentoalveolar (periapical) abscess.

- Congestive or suppurative pericoronitis, with pain, redness, and swelling of the gum, and sometimes pus, is caused by the eruption of teeth (e.g. wisdom teeth).

- Shooting pains exacerbated by movements of the tongue and swallowing, with localized swelling, are due to a suppurative cellulitis.

- Pains of variable intensity associated with bleeding gums are due to gingivitis, irritation or scurvy.

Treatment (dispensary)

All patients should receive scaling and simple instructions on dental hygiene. Specific therapy (see table 23).


Table 23

Dental infections

Infection arising as a complication of inflammation of the dental pulp.

There are three main syndromes.

LOCALIZED INFECTIONS

Dentoalveolar or periapical abscess.

- Acute: intense continuous throbbing pain, looseness of the affected tooth with expression of pus.

- Chronic: apical granuloma, sometimes with cyst formation. May be asymptomatic (incidental X-ray diagnosis) or be tender to percussion. May become reinfected.

CIRCUMSCRIBED INFECTIONS

Less localized than a periapical abscess.

- Acute serous cellulitis: swollen gum around tooth, pulsatile, mobile, with no fluctuation.

- Acute suppurative cellulitis: fever, malaise, gum swollen and very tender, with fluctuation.

- Acute gangrenous cellulitis: as with suppuration, plus crepitations on palpation.

- Chronic cellulitis: burnt out but may become secondarily infected. Marked by a painless nodule.

DIFFUSE INFECTIONS

Cellulitis that spreads through the adjacent facial and cervical tissues. May lead to necrosis and septicemia.

Dental infections may metastasize to distant sites. Think of a dental focus in cases of bacterial endocarditis, prolonged PUO, or abscess of organs.

Treatment (dispensary)


Table 24

Endemic goitre

Goitre is a swelling of the neck due to enlargement of the thyroid gland.

This may be due to problems of thyroid function (genetic deficit, hypophysohypothalamic control desorders) or a tumor.

However, the main cause of goiter in tropical countries is dietary iodine deficiency. Moreover, some food contains goitergenic factors: manioc and cruciferous (cabbage...).

Goitre is an adaptive process. The deficit in thyroid hormone synthesis due to iodine lack is compensated by a hypertrophy of the gland. Most cases of goiter are euthyroid.

Clinical features

The WHO proposes a classification according to the type of enlargement. The different grades of this classification are as follows:

- Group 0: thyroid is non palpable or palpable, but volume of the lobes is smaller than the distal phalange of the patient's thumb.

- Group 1 a: thyroid is easily palpable. The volume of the lobes is larger than the distal phalange of the patient's thumb.

- Group 1 b: as above, thyroid is visible in an extended neck, but not in normal position.

- Group 2: thyroid easily visible when the head is in normal position.

- Group 3: thyroid enlargement visible at a distance of 5 meters.

Meantime, one could also classify goiter according to its diffuse, nodular or multinodular characteristics.

Complications

- Locally: swallowing disorders, collateral circulation, tracheal compression, severe respiratory disorders, sudden enlargements especially during puberty and pregnancy. Rarely cancerous.

- Complications of subclinical hypothyroidism in pregnancy include: Low birth weight, congenital malformations and high perinatal mortality. Fetus, newborn and infant can present with hypothyroidism (cretinism with mental retardation neurological disorders and retarded psychomotor development).

Treatment

Goitre is an adaptation to a chronic lack of iodine.

Surgery should not be considered except in cases with severe complications (rare).

Prevention

The aim is to reduce the complications in new borns and infants. Prevention in the long term would have an impact on the rate of goiter in the population. There are 3 methods:

- Iodising cooking salt with iodure or potassium iodate

This technique is used in several countries and its effectiveness has been proved, but it requires a large program at national level.

- Intramusculary iodine oil injection

It has been shown that 1 ml iodine oil injections (+/- 0.48 g iode) in adults and 0.5 ml in children make goiters regress. It normalizes the thyroid function and prevents cretinism in the new-born for a period of 3 to 5 years.

For this treatment to have an impact on the community, a global program is necessary. It should not be used for individual treatment as it is relatively expensive.

- Oral iodine solution (Lugol)

Adult: 2 ml PO
Child < l year: l ml PO

This treatment is covering needs for 1 to 2 years.

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