ITEMS IN AFP WITH MESH TERM:
First Trimester Bleeding - Article
ABSTRACT: Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in distinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography. When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to future pregnancy planning, contraception, and psychological aspects of care.
When Your Patients Are in Mourning - Improving Patient Care
ABSTRACT: Grief and depression present similarly in patients who are dying. Conventional symptoms (e.g., frequent crying, weight loss, thoughts of death) used to assess for depression in these patients may be imprecise because these symptoms are also present in preparatory grief and as a part of the normal dying process. Preparatory grief is experienced by virtually all patients who are dying and can be facilitated with psychosocial support and counseling. Ongoing pharmacotherapy is generally not beneficial and may even be harmful to patients who are grieving. Evidence of disturbed self-esteem, hopelessness, an active desire to die and ruminative thoughts about death and suicide are indicative of depression in patients who are dying. Physicians should have a low threshold for treating depression in patients nearing the end of life because depression is associated with tremendous suffering and poor quality of life.
Mourners' Rights - Patient Education
Death Pronouncement: Survival Tips for Residents - Resident and Student Voice
Clinical Briefs - Clinical Briefs
Comforting a Grieving Parent - Curbside Consultation
ABSTRACT: Psychological distress is common in terminally ill persons and can be a source of great suffering. Grief is an adaptive, universal, and highly personalized response to the multiple losses that occur at the end of life. This response may be intense early on after a loss manifesting itself physically, emotionally, cognitively, behaviorally, and spiritually; however, the impact of grief on daily life generally decreases with time. Although pharmacologic interventions are not warranted for uncomplicated grief, physicians are encouraged to support patients by acknowledging their grief and encouraging the open expression of emotions. It is important for the physician to distinguish uncomplicated grief reactions from more disabling psychiatric disorders such as major depression. The symptoms of grief may overlap with those of major depression or a terminal illness or its treatment; however, grief is a distinct entity. Feelings of pervasive hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are present in patients with depression, but not in those experiencing grief. Psychotherapy and antidepressant medications reduce symptoms of distress and improve quality of life for patients with depression. Physicians may consider psychostimulants, such as methylphenidate, for patients who have depression with a life expectancy of only days to weeks.
Living with Loss - Close-ups