By G. Trano. Tennessee Wesleyan College.

The master addictions programs in counseling offer elective courses counselor certification requires (1) a minimum but do not require substance use/addiction- of 12 semester hours of graduate coursework in related course work order generic tegretol online back spasms 39 weeks pregnant. Most counseling and (3) a passing score on the examination for degree programs do not provide any addiction 103 107 master addictions counselor order tegretol 400mg without a prescription spasms meaning in telugu. Marriage and certification exam if they pass the national family therapists either must have a master’s 104 exam discount tegretol 400mg overnight delivery muscle relaxant walmart. Each state widespread use tegretol 400 mg lowest price spasms lower back, there is very little research determines the examination required for supporting the efficacy of auricular acupuncture licensure. In Alabama -that require social workers to complete and North Dakota, which do not have licensure † 113 coursework in addiction. A 1998 survey similarly found that 56 percent of licensed addiction counselors 126 Addiction counselors, also known as Substance have at least a master’s degree. Similar to addiction treatment provider staff in facilities the licensure process, certification recognizes providing addiction treatment in the United that addiction counselors have met what the 122 organization deems to be minimum standards of States. In some Addiction counselors can be licensed, certified states addiction counselors must be certified 123 129 or both. The state education qualifications for licensure vary training standards for the credentialing of ‡ 125 addiction counselors--each state certification greatly. The highest level usually documentation; and professional and ethical requires a master’s or doctorate degree. Requirements In spite of the limited education and training include: (1) a current state certificate or license requirements and the apprenticeship model of as an addiction counselor; (2) 270 contact hours training, the essential practice dimensions of of addiction counseling training; (3) three years addiction counseling are defined as including of full-time work experience or 6,000 hours of clinical evaluation; treatment planning; referral; supervised experience as an addiction counselor; service coordination; and individual, group, 138 and (4) successful completion of a written family and couples counseling --practices that 135 examination. In many states, counselors who meet only the † In states where no degree is required, certification minimum education requirements must be requirements typically include 270 hours of supervised. For no other health condition are such exemptions from  Requirements related to services to be routine governmental oversight considered delivered; or acceptable practice. District of Columbia), including the use of the Participation is voluntary and the survey does not Lexis/Nexis database to supplement information represent all treatment providers. A national The federal government does not regulate study of state-run treatment programs found that, addiction treatment facilities or programs, with excluding programs provided or operated by the the exception of those that provide opioid state addiction treatment agencies, only about 149 maintenance therapy. Like state licensing laws, these provisions include requirements regarding  13 states report that their juvenile justice staffing, services and quality assurance system operates treatment programs, with mechanisms. To be eligible to receive Medicare/Medicaid reimbursement, most treatments must be  Seven states identify their departments of provided by or under the supervision of a 151 child and family services as operating physician. State Medicaid programs have the treatment programs, with only four requiring option of covering addiction treatment under the 147 Medicaid rehabilitation option, Medicaid clinic adherence to state licensing standards. The Medicare/Medicaid programs, but in only 11 states are these Conditions of Participation impose extensive programs required to adhere to state requirements on participating facilities including 148 staffing, services and quality assurance licensing standards. While most states do not appear explicitly to address faith-based programs in their laws or regulations, some states explicitly exempt such † programs from regulation. Accreditation generally is required by federal law to obtain certification considered a higher standard of oversight than from the U. While adopting these standards maintenance programs found that voluntary 156 accreditation was strongly related to adoption of largely is voluntary, some states grant licenses 157 these practices; however, after accreditation to programs that have been accredited, such that the program is deemed to have met the state became mandatory in 2000, this relationship licensure requirements because it has been disappeared. The authors speculated that † 158 programs that voluntarily seek accreditation tend approved by a national accrediting body. By granting “deemed status” licenses to accredited to be resource-rich (in funds, staff and training) programs, the state essentially delegates to the and more motivated to improve their quality of accrediting body its responsibility for ensuring care, and therefore more likely to adopt 165 that the facility or program meets state licensure evidence-based practices. Accreditation standards are more detailed than state licensing requirements The five organizations that accredit addiction and while some require facilities and programs treatment programs and facilities in the United to use evidence-based practices or to analyze States are: 160 patient outcomes, not all do. Similarly, facilities voluntarily responding to a national federal requirements stipulate that some types of † survey: care must be provided under the supervision of a physician, while services such as “rehabilitation  56. The categories are Dentists and other health professionals may be not mutually exclusive, as programs and facilities responsible for services they are qualified to perform may have multiple accreditations. Among the 21 medical services are defined as detoxification, states that specify the minimum educational/ opioid replacement therapy or the assessment, training requirements for this position, few have diagnosis and treatment of co-occurring medical particularly high standards: or mental health conditions, not as addiction 181  Eight states require a minimum of a master’s treatment itself. Few states require non-hospital- based programs that do not provide opioid  One state requires an associate’s degree; and maintenance therapy to have a physician serving as medical director or on staff; 10 states require  One state simply requires the person to residential treatment programs to have a demonstrate competence to perform certain physician either as a medical director or on staff services. Without a physician as A national survey of treatment professionals medical director or on staff, addiction treatment conducted in 1998 found that 60. Organizations that seek percent had some college or an associate’s elective accreditation for assertive community ‡ degree and 1. In states that The Joint Commission allows programs to provide addiction treatment using Medicaid define the qualifications required for staff to funding, hospital and clinic services must be perform their job and requires staff who provide 187 provided under the direction of a physician, care to be licensed, certified or registered “in but if states choose to provide services under the accordance with the law. If physician on staff; this person must have services are required to be provided under the experience in addiction medicine, including 193 direction of a physician, the facility physician is medication-assisted treatment. Licensed health care facilities must deliver care The facility and the staff providing care also are that meets standards of medical practice; state required to hold appropriate state licenses, regulations tend to defer to health care 189 certifications or registrations. In contrast, those who providers, including addiction counselors, provide addiction treatment often have minimal comply with the credentialing requirements of 190 † their respective profession. A While most states regulate addiction treatment survey conducted in 2006 found that three services, they treat these services as completely states--Oregon, North Carolina and Alaska-- * 196 separate and distinct from medical care, and have enacted legislation that mandate or state regulations regarding addiction treatment encourage the use of evidence-based practices in service requirements vary considerably and tend addiction treatment programs; only Oregon to be vague. Accreditors specify required mandates programs to implement evidence- services in greater detail than state licensing based practices under penalty of fiscal 201 regulations, as do the federal requirements for sanctions. The federal regulate the content of addiction services by regulations for opioid maintenance therapy requiring adherence to specific guidelines, but programs include specific admission criteria, † the extent of the regulation varies considerably. In addition to listing the types of required Admission is limited to patients who meet services, the frequency and timing of services clinical diagnostic criteria for opioid § are specified in some cases; for example, dependence and the person must currently have patients receiving detoxification must receive a addiction and must have become addicted within ** psychosocial assessment within 72 hours of one year before treatment admission. A 197 admission or patients in intensive outpatient physician must perform a full medical programs must receive individual or group examination before admission. Opioid therapy for a minimum of six hours over at least maintenance therapy programs must provide 198 two days a week. State regulations related to addiction treatment ‡ The Department of Corrections, the Oregon Youth services tend to specify the categories of Authority, the State Commission on Children and services that addiction facilities and programs Families and the part of the Oregon Health Authority must offer--such as individual, family and group that deals with mental health and addiction issues.

Spontaneous dyskinesia found in 12% of spectrum subjects order tegretol with a visa 2410 muscle relaxant, especially in schizotypals (24%) discount tegretol 100mg with visa spasms under xiphoid process. Indian study finds that dyskinesia (but not Parkinsonism) is more common in never-treated siblings of schizophrenics who have the (corresponding) movement disorder buy tegretol cheap online muscle relaxant for alcoholism. Patient sits on firm armless chair buy 100 mg tegretol spasms left abdomen, hands on knees, legs slightly apart, feet flat on floor – now and throughout examination observe entire body. Patient taps thumb against each finger for 15 seconds with each hand – observe face and legs. Movements that occur only on activation merit 1 point less than spontaneous movements. Neither is there agreement thay atypical drugs are necessarily better than haloperidol in terms of cognitive improvement. Actions on serotonergic systems may underlie improved 3762 profiles among atypical agents , such as improvement in negative symptoms, although whether these drugs tackle primary or secondary negativity (e. Alternatively, atypicals block D2 receptors for relatively brief periods as with clozapine or (in the case of aripiprazole) act as partial agonists at D2 receptors. One study suggested that risperidone plus a mood stabiliser was more efficacious than a mood stabiliser alone, and as efficacious as haloperidol plus a mood stabiliser for rapid control of mania. Clozapine aside, the clinician would do well to choose an antipsychotic drug on the basis of its pharmacological and side-effect profile rather than whether it belongs to the novel/atypical/second generation or is an old/typical/first generation compound. Geddes ea (2000) conclude that when the dose of typical drugs is controlled for they are as 3765 efficacious and as tolerable as the atypical antipsychotics. Chakos ea (2001) concluded that clozapine was more effective than typical drugs, but probably not by a robust margin, and the evidence, they found, was inconclusive for other new agents. Mortimer(2002) stated that the most powerful predictor’ of ‘atypicality’ is fast dissociation of the drug from D2 receptors: as measured by the Koff, clozapine and quetiapine have the fastest dissociation. A more satisfactory term is ‘novel’ antipsychotics, but this would omit clozapine. A scientific definition of an atypical antipsychotic drug is that (unlike typical drugs) it doesn’t cause catalepsy in rats. In real-life clinical practice, there is only one sure way of knowing who will respond to a particular drug, and that means trying it. Some patients for example respond to risperidone and not to clozapine and vice versa. Davis ea, (2003) in a meta-analytic study, found that clozapine, 3766 amisulpride, risperidone and olanzapine were more efficacious than first-generation antipsychotics. Unlike Geddes ea, (2000) Davis ea (2003) did not find that the dose of haloperidol or other first-generation antipsychotics affected these results, and the latter authors found no difference in efficacy between amisulpride, risperidone and olanzapine. McCue ea (2006) found haloperidol, olanzapine, and risperidone superior to aripiprazole, quetiapine, and ziprasidone in the treatment of acute schizophrenia. Robinson ea (2006) used olanzapine or risperidone for first-episode schizophrenia: clinical outcomes were equal and olanzapine caused less motor side effects but caused more weight gain. Leucht ea (2009b) analysed 78 studies of schizophrenia patients and found olanzapine superior to aripiprazole, quetiapine, risperidone, and ziprasidone; risperidone was better than quetiapine and ziprasidone; clozapine was superior to zotepine and (if dose was > 400 mg/day) risperidone; such differences as there were derived from reduction in positive but not negative symptoms. The authors stated that results ‘were rather robust’ in relation to the influence of pharmaceutical industry sponsorship, the quality of research, doses, and duration of trials! Despite some methodological deficiencies, research indicates that atypical antipsychotic drugs help to prevent relapse in schizophrenia. Turrone ea, 2002) The risk for dysglycaemia is doubled in community-based treated schizophrenic patients compared to the general population, and recognition and treatment of diabetes and pre- diabetes is low in this group. In a prospective randomised study, Lindenmayer ea (2003) found that clozapine, olanzapine, and haloperidol were associated with increased plasma glucose values, and the two atypicals were associated with increased plasma cholesterol levels. Elevated serum triglyceride levels has been recorded in patients taking phenothiazines, clozapine, olanzapine, and quetiapine. The en masse withdrawal of these drugs that followed warnings of increased (about threefold from 3766 But not aripiprazole, quetiapine, remoxepride, sertindole, ziprasidone, or zotepine. Individual patient circumstances and the side effect profile of alternatives should come first, i. Herrmann ea (2004) and Gill ea (2005) found no excess of cerebrovascular incidents in elderly people given atypicals compared to those given typical antipsychotics, but Gill ea (2007) did find early increase in mortality (typical > atypical antipsychotics). Mehta ea (2010) conducted a retrospective study of community-dwelling older adults and found that second generation antipsychotic agents were associated with an increased risk of cerebrovascular incidents compared to first generation drugs and that long-term use of either of these classes of drug were associated with an increased risk of such adverse events. There is more research evidence for the effectiveness of atypical drugs in managing behavioural and psychiatric symptoms in people with dementia than for the typical drugs. Patients should only be retained on these drugs (after due consultation) if they have responded to them, if the behavioural problem is persistent or if severe adverse consequences are likely to follow their discontinuation, or if no suitable alternatives exist. It is good practice, however, to keep such prescribing under review (say, every 3 months) and to document why a decision is made. Also, if adverse effects become burdensome (as often happens), the clinician may need to withdraw the medication or modify the dosing regimen. Clozapine is indicated for nonresponse to or intolerance to other antipsychotics and for treatment of unresponsive psychosis in Parkinson’s disease. Clozapine is said to improve both positive and negative symptoms of schizophrenia, although some results suggest that such negative symptoms may actually represent withdrawal responses to positive symptoms, and not all results agree that negative symptoms are helped. It is thought to improve 30-50% of patients in the former category and 70-76% in the latter group. Possible reasons for lack of neurological adverse effects of clozapine Potent anticholinergic action Preferential binding: limbic > striatum 3768 5-H dibenzo [be, e]-1, 4-diazepine; synthesised in 1958; found effective for schizophrenia in 1962; originally developed by Hünziker and co-workers. Ashkenazi Jews and Finns may be at special risk of agranulocytosis from clozapine.

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Some buy tegretol in united states online muscle relaxant tramadol, such as postexposure weaning and subsequent second-gen- Largely because early testing of drugs occurred in eration drug effect studies will be time-consuming males rather than females cheap 400mg tegretol with visa spasms down left leg, for reasons discussed and expensive 200mg tegretol with visa muscle relaxant renal failure. The logistics of running Phase I single-dose and multiple-dose It has been stated that large numbers of mature ranging studies while controlling for a natural men- women are volunteering for the new lipid buy tegretol 400mg otc spasms 1983 wikipedia, heart strual cycle are truly horrendous, both for the risk, osteoporosis and arthritis studies, due to Phase I testing units and for the volunteer. It will readily be appreci- together, single, multiple, and multiple-dose ated that most drugs or devices are not unique or ranging studies, with food effect studies and extra life saving but hopefully an improvement on staff costs, could add $1 million to development existing agents, and indeed this applies to most costs and very rarely show a difference which basic research experiments. Some studies have shown that women demonstrate greater duration in the gastric residence time of The Weight/Dose Problem medications, which is reflected in an increased lag time of absorption, compared to men. This effect is A casual appraisal of ideal weight-for-height tables increased when medication is taken with food, even for males and females (Metropolitan Life Insur- when adjusted for the timing of the menstrual cycle ance, 1999) shows clear differences between males (Majaverian et al, 1987). Miaskiewicz et al (1982) showed that, from 50 at 106 pounds to 6 80 00 at 226 pounds; in after a single dose of sodium salicylate, absorption females, it varies from 85 pounds at 4 90 00 to 185 was slower and achieved a lower level in women. For both sexes this represents a was observed to be more than 54 min in females, 46% differential in healthy weight while taking the compared to a Tmax of 31. First, the majority of the binding capacity have been reported (Miaskiewicz population falls towards the middle of the height± et al, 1982) and, for other agents (Allen and Green- weight levels, rather than the extremes. Second, blatt, 1981), g-globulin transport systems have most drugs have a wide range where which they been reported to be altered with the menstrual exert therapeutic effect before efficacy levels off. Third, the level of unacceptable adverse events Some effects on absorption can be subtle, such as generally occurs at much higher doses than the the greater absorption of alcohol in women due to therapeutic level for most drugs (there are some their reduced gastric mucosal and liver alcohol notable exceptions, e. Propranolol is still one of the most frequently used In animals, estrogen has been shown to influence b blockers (National Prescription Audit, 1989), but the effect of antidepressants on the brain. Wilson Walle et al (1985) reported that women had higher showed that estradiol increased the binding of imi- plasma levels of propranolol than men following pramine to the uptake of serotonin at membrane single oral dosing and, in an additional study, sites. Estrone had no effect, but the addition of showed that on multiple dosing, propranolol progesterone to low doses of estrogen increased steady-state (trough) plasma levels were 80% this effect. It is of interest that men, used as westa et al, 1986) and antimigraine medications, a control, only sustained levels at the level of day seen with the fluctuation of the menstrual cycle 1 in women (Wilson et al 1982). Differences between males and females in the Young women appear to be the group most at risk amount of free drug found in plasma, and of pro- of developing extrapyramidal reactions when taking tein binding, have been reported for diazepam the antinausea drug metoclopramide. Another age/gender-related effect is seen stance, a direct correlation was found with differ- in older women who have become newly postme- ences in lipoprotein and orosomucoid protein nopausal and who are still taking antipsychotic (1-a-acid glycoprotein) fractions (Greenblatt et al, medications, because the symptoms of tardative 1980). In women, oxazepam has been found to be dyskinesia may appear or even worsen (Smith eliminated at a slower rate, about (10%), and for and Baldossarini, 1973). Twice as many Circulating hormones, such as aldosterone and women are treated for depression and anxiety neur- renin have long been known to fluctuate with the osis than men, first described by Raskin (1974), and menstrual luteal phase. If oral contraceptives are given, then chemical differences, for women are more likely to an increase of these hormones is also seen in the seek help than men. In women of all ages, Tran et al (1998) also ible contraceptive precautions and those with reported that, in findings from records of 2367 vasectomized partners. More than one 1993), perhaps spurred by its own findings in 1989, agent was reported to be responsible in 50% of and confirmed by the General Accounting Office female patients vs. It is possible that bare arms and exposed population, and young women in large numbers legs in women may cause more phototoxic reac- (Bush et al, 1993). Clearly, these two classes adequately discuss gender difference, which would of agents need special gender exploration in clinical be addressed in the new amended guideline. It called for all research on human sub- All 33 responding companies collect gender-related jects concerning drugs, devices, epidemiology, non- data on the participant patients in clinical studies. By December 1999, there were study ought to be undertaken, and then a shorter 348 medicines in development for diseases only in duration efficacy and safety study in women. Of those who saw differences, only larger, because a difference in low-incidence ad- one-third found these differences to be clinically verse events will not show up until the drug is on significant 5% of the time, while 17% of respond- the market. Subjects Indeed, diseases such as endometriosis can only be studied in such a population, whereas drugs to treat Women should be and, indeed, are included into urinary incontinence would be better undertaken in new drug and device development programs when older patients. While possible, this is not gen- The Potential Child-bearing Population erally a widely applicable solution, because geo- graphic, environmental and volunteer numbers The probability of potential early embryonic ex- now become added variables. When a woman of childbearing age participates in a research procedure in which there is a risk to the fetus, the nature of the risk being either known or unknown, she should be advised that, if she wishes Liabilities for Fetal Damage to be a subject, she should avoid becoming preg- nant. Such research may expose the insti- tution to risk of liability for damage to subjects; example of the National Vaccine Injury Act of however, that is inherent in research involving October 1988, where a trust fund was set up derived human subjects anyway, and there are many from an excise tax imposed on each vaccine. Not to do such funds, through an arbitration panel, are used to research, while it may serve to protect the interests compensate persons injured by vaccination. Data in women are needed and the possibility is suggested of an Gender-related differences do exist in drug hand- expanded National Register along the lines of the ling, but in general are relatively clinically insignifi- International Clearing House for Birth Defects cant. Theoretically, because of weight differences, Monitoring to follow up the expected small number women may receive more medication than men of embryos exposed and a Compensation Panel in for a standard dose when converted to mg/kg. It is suggested that women continue ences, and with enhanced computer power, this to be enrolled into most drug study programs, chapter may become moot. Sadly, the mortality rate This chapter will focus on the current regulatory of children in Third-World countries is 10 times requirements, their background, the clinical study, higher than in the developed world. Substantial additional testing in animals Clearly, firms needed further encouragement and in humans was required prior to marketing to submit additional pediatric data, so in 1997 approval. This called for firms to submit data drugs in children did not advance at a similar on children to support labeling for a new pediatric pace, and most drugs (unless specifically intended subsection before the drug could be approved. Eventually, academia 1999, governing the need for pediatric studies, would publish a series of cases, so giving guidance and extending the requirements to biological on dosing and likely toxic effects. As might be expected, the generic companies tions did exist for some drugs, but mainly for are appealing this interpretation of the pediatric use in the elderly.

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Given the rapid young women with early breast cancer has essential to promote women’s well-being and with the primary physician buy 200 mg tegretol fast delivery spasms posterior knee, a woman would progress in reproductive medicine of the past like the opportunity to consider pregnancy decade purchase tegretol once a day muscle relaxant voltaren, it is likely that new and advanced been developed (M buy online tegretol kidney spasms causes. Treatment of breast cancer with breast cancer fnd that children bring normalcy physiology buy cheap tegretol muscle relaxant johnny english, preservation and the role of Br Med J 1977;2:1524–7 trastuzumab during pregnancy. The relation of carcinoma 2007;110:507–10 conceive have a similar survival compared with and fuorouracil in patients with axillary node- of the breast and pregnancy in 283 patients. Shrim A, Garcia-Bournissen F, Maxwell C, those who do not, when taking into account positive breast cancer: an update of the Guy’s/ Surg Gynecol Obstet 1962;115:65–71 Farine D, Koren G. Preg- 2006;24:321–2 who have a good prognosis need not wait 2 Pregnancy after breast cancer: population based nancy and offspring after adjuvant chemo- 37. Herceptin (trastuzumab) therapy 2005;96:95–108 early breast cancer need to make endocrine Gynecol 1994;170:818–23 during pregnancy: association with reversible 42. Cancer mation needs of younger women with a diag- Surg Clin North Am 1995;75(1):47–51 cancer with trastuzumab and vinorelbine dur- 1997;79:1271–8 nosis of breast cancer: a qualitative study. Today approximately 2% of women of childbearing age with a renal trans- Impaired fertility is common in women with plant become pregnant9, and the literature end-stage organ disease. Despite this, unplanned pregnancies should occur prior to transplantation in order do occur, and all women of childbearing age for pregnancy to be planned at the optimum with end-stage organ disease should be pro- time in terms of maintaining good graft func- vided contraceptive advice. The frst success- ful pregnancy following renal transplantation Restoration of fertility, and hence the ability was reported in 19586 and after orthotopic to conceive, usually occurs fairly rapidly fol- liver transplantation in 19787. In the early years after lung transplantation, however, post-transplant period, pregnancy is less likely the risk of acute rejection is reduced, and as to be successful when the degree of immuno- with other solid organ transplants recipients, suppression and the risk of acute rejection and patients will be maintained on lower doses of 18 Criteria and baseline investigations common to all solid organ transplant recipients infection all are generally highest. Although the choice of contra- bly somewhere between 12 months and 5 years Good general health ceptive method is essentially arbitrary, many post-transplant19. In addition to stable graft No recent episodes of acute rejection and no evidence of ongoing rejection physicians prefer long-acting forms of contra- function and absence of recent rejection epi- No evidence of acute infection 8 Stable immunosuppressive regimen ception to ensure adequate protection. They may also increase the adherence to the published recommenda- 10 15 Appropriate preconception counseling for inheritable conditions risk of intrauterine infections. For renal transplant recipi- not fulfl the recommended criteria regarding ents, this typically means a serum creatinine of timing of pregnancy choose to become preg- Recommended organ-specific baselne criteria and investigations less than 133μmol/l (<1. In 2003, a consensus conference held by the Any pregnancy in a solid organ transplant Heart Lung Kidney Women’s Health Committee of the American recipient should be considered high risk. In this eventuality, it is ther pregnancies do not adversely affect graft pharmacists and other health professionals, pregnancy for at least 1 year post-transplan- important that the entire clinical picture be function provided that graft function is good at should be offered to the solid organ trans- tation and preferably 2 years16. Cardiac transplantation in patients that acute rejection rates during pregnancy successful in vitro fertilization in female renal The underlying reason for organ transplanta- with mitochondrial myopathies has been are low and are indeed no higher than in non- transplant recipients23,24 and also of intracyto- tion may have implications for the pregnancy reported32. A number of during pregnancy, a factor which can increase plasmic sperm injection for male renal trans- conditions can be transmitted to offspring, plant recipients with infertility25. Although neither cyclo- have an electrocardiogram and an echocar- that their child may inherit the same condi- prior to conception the patient should be sporine nor tacrolimus has been reported to diogram17. If the maternal diagnosis is known dur- vaccinated against infuenza, pneumococ- be teratogenic or mutagenic, both have been angiography (to exclude allograft coronary ing the pregnancy, antenatal ultrasound may cus, hepatitis B and tetanus17. Women who associated with low birth weight, intrauterine artery disease), right heart catheterization and be used to look for the typical changes of refux are not rubella immune should receive the growth retardation and small size for gesta- cardiac biopsies, but these tests may not be nephropathy in the fetus29. Prenatal testing ued during the pregnancy to avoid graft rejec- as an immunosuppressive agent following It is not uncommon for recipients of both may be available for certain conditions1. Studies in pregnant rats have Reports indicate that sirolimus is associated rine and no drug-related problems have been offspring of treated rats and rabbits showing shown that whilst sirolimus is not teratogenic, with altered sex hormone levels (low testos- noted in their babies35. A case was described wherein a 30-year- sirolimus-associated infertility in a young male azathioprine, the consensus opinion for tacro- matic hernias38,39. Sperm quality improved limus is that breastfeeding is not absolutely A number of case reports presently describe healthy normal baby at term having taken following the withdrawal of sirolimus and the contraindicated, but babies should be closely congenital abnormalities following human sirolimus throughout the pregnancy41. Two maternal deaths occurred when recommended during pregnancy and should motility, although sperm count and morphol- Milk concentrations range from 5 to 25% of immunosuppression was discontinued during be discontinued at least 6 weeks before con- ogy are not completely restored to normal44. In cardiac transplant recipients, ception is attempted, during which time effec- The true incidence and prevalence of male are found in breast milk following a 10mg there is a high risk of acute rejection in preg- tive contraception should be used. Nei- ever, small studies have shown no evidence as a biopsy usually involves X-ray screening malformations, notably involving development ther azathioprine nor calcineurin inhibitors of harm in the babies of azathioprine-treated which is contraindicated in pregnancy. It is a major cause Table 1 Characteristics of pregnancy among transplant recipients during pregnancy and of their infants, function during a pregnancy. The increased glomerular fltration rate eclampsia and resulting increases in the risk Characteristic Kidney Liver and kidney Heart Lung which occurs in pregnancy usually results in of fetal growth restriction, placental abruption No. Hypertension is common in the solid organ Diabetes during pregnancy (%) 3–12 0–13 2 4 21 For patients with liver transplants, any dete- transplant recipient even before pregnancy, Rejection episodes (%) 2–12 0–11 6 22 31 rioration in liver chemistry during the preg- and particularly if the patient is receiving a Pre-eclampsia (%) 29–31 13–33 33 10 13 nancy requires aggressive evaluation. Graft loss within 2 years (%) 4–14 3–9 17 0 23 no contraindication to liver biopsy, if required, The incidence rates of both hypertension and to look for evidence of rejection1. Pre-eclampsia develops in 15–37% of Reproduced with permission from McKay and Josephson8 from graft rejection and exacerbation of under- renal transplant recipients58 and is reportedly lying liver disease such as hepatitis C1. Lower rates have been reported underlying renal impairment, reduce maternal Other beta blockers are safe in pregnancy and given to treat an acute rejection episode and is in liver, heart and lung recipients53. It is essential hydralazine has been extensively used in preg- hypertension and a 10% rate of pre-eclampsia 62 that these are reviewed ideally before concep- nancy with few adverse events reported. A recent study reported Hypertension is a common medical disorder ally be maintained at less than 140/90mmHg associated with small-for-gestational age a 2. However, in cases of severe edema the ent in patients with diabetic nephropathy The overall risk of infection during pregnancy transplantation year when levels of immuno- risk–beneft ratio of diuretic therapy should be affecting a transplanted kidney, especially if varies according to the organ transplanted. Low-dose prophylactic aspirin helps prevent A patient whose diabetes is normally treated Bacterial infections laxis is also advised in cases where the donor pre-eclampsia75. Few studies, however, have with oral hypoglycemic agents may require and recipient are both seropositive and the specifcally examined the purported beneft in insulin during pregnancy. Aciclovir is not known to weeks in the high-risk patient if there are no Approximately 1–2% of patients on the renal that all renal transplant recipients should be be harmful in pregnancy, but its manufactur- contraindications58. If asymptom- when the potential benefts outweigh any nancy is often a consideration for this category atic bacteriuria is present, a course of antibiot- risks47.

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