Este documento discute varios temas relacionados con el embarazo y la nutrición materna. Resalta que una nutrición inadecuada durante el embarazo puede conducir a problemas como restricción del crecimiento intrauterino y bajo peso al nacer. Recomienda que la madre reciba los nutrientes adecuados como ácido fólico, hierro y calcio. También analiza factores de riesgo para el crecimiento fetal como la obesidad, bajo peso y edad gestacional, y métodos para monitorear el bienestar fetal como dop
Criterios de severidad en tec en pediatría - CICAT-SALUDCICAT SALUD
Este documento describe los criterios clínicos para determinar la severidad de un trauma craneal pediátrico. El criterio más importante es el examen clínico, apoyado por tomografía. Un trauma es más grave si el paciente cayó de menos de 1 metro, pesa más, tiene enfermedades previas, fue herido por un arma de fuego de mayor calibre, estuvo inconsciente más de 20 minutos, iba en un vehículo a alta velocidad sin protección, presenta midriasis unilateral, puntaje bajo en la escala de Glasgow, falta de
Este documento discute varios temas relacionados con el embarazo y la nutrición materna. Resalta que una nutrición inadecuada durante el embarazo puede conducir a problemas como restricción del crecimiento intrauterino y bajo peso al nacer. Recomienda que la madre reciba los nutrientes adecuados como ácido fólico, hierro y calcio. También analiza factores de riesgo para el crecimiento fetal como la obesidad, bajo peso y edad gestacional, y métodos para monitorear el bienestar fetal como dop
Criterios de severidad en tec en pediatría - CICAT-SALUDCICAT SALUD
Este documento describe los criterios clínicos para determinar la severidad de un trauma craneal pediátrico. El criterio más importante es el examen clínico, apoyado por tomografía. Un trauma es más grave si el paciente cayó de menos de 1 metro, pesa más, tiene enfermedades previas, fue herido por un arma de fuego de mayor calibre, estuvo inconsciente más de 20 minutos, iba en un vehículo a alta velocidad sin protección, presenta midriasis unilateral, puntaje bajo en la escala de Glasgow, falta de
O documento é uma celebração religiosa em homenagem a Gustavo Scheffer que inclui orações, hinos, leituras bíblicas e uma homilia pedindo a intercessão de Santo Antônio para o povo brasileiro.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
O documento descreve o regulamento de um concurso de leitura organizado pela Rede de Bibliotecas de Tábua em Portugal. O concurso é dividido em três fases e tem como objetivo estimular a leitura entre estudantes do 1o e 2o ciclos do ensino básico. Os vencedores receberão certificados, livros e outros prêmios.
O documento discute como começar o dia focando em Deus. Sugere que ao invés de se preocupar com os problemas, deve-se começar o dia orando e colocando Deus como o primeiro pensamento. Isso trará paz e ajudará a tomar melhores decisões. A bíblia ensina a começar com Deus, assim como uma música fala em fazê-Lo o primeiro pensamento de cada manhã.
El documento describe un entendimiento entre los gobiernos de Estados Unidos y Colombia sobre el Capítulo 16 del Acuerdo de Promoción Comercial entre los dos países. El entendimiento establece que cualquier parte podrá solicitar revisar la aplicación del Artículo 16.7.9 dos años después de la entrada en vigor del acuerdo si hay un cambio significativo en la tecnología para limitar la recepción de transmisiones por Internet. La otra parte deberá acceder a consultas sobre una posible modificación al artículo.
La Unión Europea ha acordado un embargo petrolero contra Rusia en respuesta a la invasión de Ucrania. El embargo prohibirá las importaciones marítimas de petróleo ruso a la UE y pondrá fin a las entregas a través de oleoductos dentro de seis meses. Esta medida forma parte de un sexto paquete de sanciones de la UE destinadas a aumentar la presión económica sobre Moscú y privar al Kremlin de fondos para financiar su guerra.
Este documento es una colección de mensajes, fotos y resultados de partidos que celebran las victorias y logros de un niño llamado "Luquitas" en su carrera como jugador de fútbol en el club River Plate. Se destacan varios títulos ganados por River Plate en diferentes torneos, y se expresa el orgullo y amor que siente el autor por Luquitas y su talento para el fútbol.
El documento presenta el Campus100TIC organizado por el Consorcio IdenTIC, un campamento de verano para niños de 8 a 12 años centrado en la ciencia y la tecnología. Se ofrecen dos modalidades, campamento de verano o urbano, con actividades como robótica, programación e idiomas. El campus tendrá lugar en las instalaciones del Centro de Formación Creofonte en Casar de Cáceres y la inscripción se realiza en línea.
El documento presenta información sobre la gestión ambiental y la valoración de bienes no mercadeables. Explica conceptos como el ecoturismo, sus características y principios, así como ejemplos de parques ecoturísticos en Colombia como Los Nevados y Amacayacu. Finalmente, destaca nuevas alternativas ecoturísticas en Cabo de la Vela y el papel de las instituciones educativas en la promoción del desarrollo sostenible.
Offrant un moyen simple de répartir des composants dans différentes machines virtuelles Java et d'assurer leur re-démarrage en cas d'erreur, la plateforme PSEM2M a rempli une bonne partie de ses objectifs. Les prochaines itérations de son développement ajouteront la capacité de la plateforme à réagir face à des indisponibilités ou des crashs chroniques ou critiques de services, ainsi que la gestion d'isolats hétérogènes (Python, ...).
6.1.3 génesis histórica de la crisis ambiental económica gaUniambiental
Este documento resume la historia de la crisis ambiental económica en 3 etapas: 1) Desde el origen humano hasta la revolución neolítica, 2) Desde el neolítico hasta la revolución agrícola del siglo XVIII, 3) Desde allí hasta la revolución verde del siglo XX. Explica cómo los cambios en las técnicas agrícolas han permitido un crecimiento demográfico exponencial que ejerce gran presión sobre los recursos naturales y el medio ambiente.
The World Health Organization (WHO) defined «healthy ageing»
as the process of developing and maintaining the functional ability
that enables wellbeing in older age.
Functional ability is referred to as the ability to:
- meet their basic needs,
- learn, grow and make decisions,
- be mobile,
- build and maintain relationships, and
- contribute to society
WHO describes this functional ability as being formed by interactions between intrinsic capacity and environmental characteristics.
The intrinsic capacity includes the mental and physical capacities of a person.
The environmental characteristics are related to home, community and society as a whole.
Management of menopausal symptoms for breast cancer survivorsTevfik Yoldemir
This document summarizes management strategies for menopausal symptoms in breast cancer survivors. It discusses pharmacological options like clonidine, oxybutynin, antidepressants, black cohosh, and phytoestrogens. It also covers mind-body practices like cognitive behavioral therapy and hypnosis. Non-hormonal treatments for vulvo-vaginal symptoms are discussed, as well as short-term low-dose local estrogen therapy. Management of menopausal symptoms requires a personalized approach balancing symptom relief with safety.
The document discusses several studies related to endometriosis and IVF outcomes. It provides summaries of studies that examined:
- Live birth rates, clinical pregnancy rates, number of oocytes retrieved, and miscarriage rates for patients with endometriosis undergoing IVF compared to controls.
- IVF outcomes based on the severity of endometriosis compared to controls.
- Outcomes of fresh versus frozen embryo transfers.
- The risk of embryonic aneuploidy in patients with endometriosis.
- Treatment guidelines from ESHRE on the use of IVF and surgery for infertility associated with endometriosis.
Pelvic anatomy in relation with pelvic organ prolapseTevfik Yoldemir
The document discusses pelvic organ prolapse from an anatomical perspective. It describes the layers of fascia and muscles that provide support to the pelvic organs. Damage to the fascia can result in cystocele, rectocele, or uterine prolapse as the pelvic organs lose support and protrude into the vaginal canal. The document outlines the components of the pelvic floor according to the Integral Theory and how dysfunction, such as stress urinary incontinence, can result from weakness or damage in specific areas. Assessment tools like the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire are also mentioned for evaluating patients.
Certain viruses can be transmitted from mother to fetus during pregnancy and cause fetal or neonatal damage. These include cytomegalovirus, rubella virus, varicella zoster virus, herpes simplex virus, and parvovirus B19. Cytomegalovirus is the most common cause, with an estimated 1% of newborns infected worldwide. Severe damage from cytomegalovirus, such as cytomegalic inclusion disease, occurs in about 1 in 5,000 to 1 in 20,000 births. Transmission is more likely when a mother has a primary infection compared to a recurrent infection. Clinical manifestations in the newborn are also more common following primary maternal infection.
This document discusses different types of energy modalities used in surgery including monopolar, bipolar, ultrasonic, and plasma kinetic technologies. Monopolar energy uses an active electrode at the surgical site and a return electrode elsewhere on the patient's body, allowing for tissue cutting, coagulation, and desiccation. Bipolar energy passes between two close electrodes, minimizing collateral damage. Advanced bipolar technologies like Ligasure, Plasma Kinetic Gyrus, and Enseal can additionally seal and transect tissue. Ultrasonic devices use high frequency vibrations to denature proteins for coagulation and mechanical cutting. The effects of different energies on tissue are described, noting temperatures at which protein denaturation and
This document discusses techniques for diagnosing endometriosis, including magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS). It provides details on MRI protocols, including patient preparation, positioning, and rectal opacification. It also outlines four basic steps for a TVS exam when evaluating for deep infiltrating endometriosis: 1) evaluating the uterus and adnexa; 2) assessing for soft markers like tenderness and ovarian mobility; 3) using the "sliding sign" to assess the pouch of Douglas; and 4) searching for endometriosis nodules. The document also discusses agreement between observers for diagnosing deep infiltrating endometriosis using TVS in different pelvic
This document summarizes research on the effects of alternative hormonal treatments, including bazedoxifene, on various tissues in humans. It discusses preclinical and clinical data on the effects of ospemifene, tamoxifen, raloxifene, and bazedoxifene on the endometrium, vagina, breast, and bone. It then summarizes results from several clinical trials, known as the SMART trials, that evaluated the efficacy and safety of a combination of conjugated estrogens and bazedoxifene for vasomotor symptoms, quality of life, vaginal health, and bone mineral density and fracture risk reduction.
1. The document discusses premature ovarian insufficiency (POI), including delays in diagnosis contributing to low bone density. For every month of delayed diagnosis, spine bone mineral density decreases by 0.026.
2. POI can manifest as delayed puberty, primary or secondary amenorrhea, or irregular periods. Genetic factors are responsible for some cases, with mutations in meiotic and DNA repair genes linked to syndromic and non-syndromic POI.
3. Treatment of POI involves hormone replacement therapy to mimic normal estrogen and progesterone levels. Estrogen therapy should begin at age 12-13 and be gradually increased over 2-3 years. Progestogen is later added for endometrial protection
This document discusses menopause and osteoporosis, including clinical risk factors for osteoporosis, indications for bone mineral density testing, hip fractures and biochemical markers of bone turnover. It also addresses calcium content of food, pharmacologic agents for osteoporosis, changes in lumbar spine and total hip bone mineral density, vertebral and non-vertebral fractures, and risks and benefits of hormone replacement therapy, including its effects on cardiovascular disease, cancer risks, and risks of breast and endometrial cancer. Contact information is provided for further questions.
This document discusses tests that should be performed before various forms of contraception including IUD insertion, implant insertion, DMPA initiation, OCP use, and POP initiation. It also mentions that follow-up is important and that PID can sometimes be found in IUD users. The document is authored by Tevfik Yoldemir MD BSc MA and provides his contact information and links to additional information on contraception.
The document provides treatment guidelines for several sexually transmitted infections (STIs):
- Chancroid is diagnosed based on painful genital ulcers and lymphadenopathy. It is treated with azithromycin, ceftriaxone, ciprofloxacin, or erythromycin.
- Herpes is typically treated with acyclovir, valacyclovir, or famciclovir for suppressive or episodic therapy. Pregnant women may take acyclovir or valacyclovir.
- Syphilis treatment depends on stage, and involves benzathine penicillin for most cases.
This document contains a summary of topics related to early pregnancy complications and abortion. It lists bleeding in early pregnancy, ectopic pregnancy, risk factors and algorithms for diagnosis, methotrexate protocol, molar pregnancy symptoms and management, and habitual abortion as sections within the document. Contact information is provided for Dr. Tevfik Yoldemir as the author along with links to additional resources on these medical topics.
This document discusses menstrual cycle disorders and their causes and treatment. It defines menorrhagia as heavy menses in ovulatory women, and metrorrhagia as irregular bleeding during an ovulatory cycle. Common causes of abnormal uterine bleeding (AUB) include uterine fibroids, endometrial polyps, and adenomyosis. Evaluation of AUB may involve a saline-infused sonogram. Medical treatments aim to regulate hormone levels and bleeding patterns through contraceptives and cyclic progestin-only regimens.
This document discusses chronic pelvic pain and associated disorders. It covers chronic pelvic pain disorders, different physical examination positions, diagnostic tests, endometriosis, and provides contact information for questions. The document appears to be notes from a presentation or article on evaluating and diagnosing chronic pelvic pain and conditions that may cause it such as endometriosis.
This document summarizes research on endometriosis beyond late reproductive age. It discusses findings that endometriosis persists and can recur even after menopause. Studies show endometriosis symptoms continue across all age groups and surgical recurrence rates remain high. Hormone replacement therapy after menopause may increase risk of endometriosis recurrence and malignant transformation. Emerging treatments for endometriosis that are discussed include GnRH antagonists, aromatase inhibitors, and other drug classes targeting factors like angiogenesis and inflammation.
This document summarizes several studies on the impact of fibroids on fertility and in vitro fertilization (IVF) outcomes. It discusses factors like sample size calculations, reliability and validity of research data, and potential confounding factors in sham surgery trials. It then summarizes multiple studies that found no significant impact or decreased live birth rates with intramural fibroids not distorting the uterine cavity compared to controls without fibroids undergoing IVF. The document provides an expert review of the evidence on fibroids and fertility.
1. The document discusses fertility options for women over age 40, what is realistic and not realistic. It provides data from studies on pregnancy rates by age and discusses strategies like tailored stimulation protocols, embryo selection techniques, and oocyte accumulation.
2. Case studies are presented of women over 40 concerned about their fertility. The document recommends counseling based on AMH, AFC, prior response and discussing tailored protocols, cumulative success rates, and alternative options.
3. Strategies discussed include minimal or double stimulation protocols, embryo banking, oocyte donation, and new selection techniques, but individualized assessment is important due to variability.
- Maternal nutrition and environmental exposures during pregnancy can impact the fetal epigenome through DNA methylation, histone modifications, and microRNAs. This can increase the risk of health issues like metabolic syndrome later in life.
- Certain phytochemicals from foods like epigallocatechin gallate, resveratrol, genistein, and curcumin may beneficially influence the fetal epigenome by regulating enzymes involved in epigenetic modifications.
- Adequate intake of nutrients like vitamins, minerals, and phytochemicals during pregnancy and lactation may help protect the offspring by modulating the fetal epigenome.
1. 21.12.2013
1
Optimal Ovulasyon İndüksiyonu
nasıl olmalı ?
Dr Tevfik Yoldemir
Marmara Üniversitesi Tıp Fakültesi
Kadın Hastalıkları ve Doğum A.D.
tevfik@yoldemir.com
Pato-fizyoloji
LH
+
17-OH P A4
Teka hücresi
P4
Granuloza hücresi
E2
FSH
+
aromatizasyon
Iki hücre , iki
hormon teorisi
Errrrkkkkeeeennnn ffffoooollll.... ffffaaaazzzz
Iki hücre , iki
hormon teorisi
Pato-fizyoloji
LH
+
17-OH P A4
Teka hücresi
P4
LH
+
Granuloza hücresi
E2
FSH
+
aromatizasyon
GGGGeeeeçççç ffffoooollll.... ffffaaaazzzz
Folikül >13mm
Anovulatuar PKOS
Short analog
Hipo-hipo
2. 21.12.2013
2
Ovulation induction with a starting dose of 50 IU of recombinant follicle
stimulating hormone in WHO group II anovulatory women: the IO-50 study, a
prospective, observational, multicentre, open trial
Joaquim Calaf Alsina, 2003
Çoğul gebelik şansı DSÖ II
3. 21.12.2013
3
DSÖ II DSÖ II
DSÖ II DSÖ II - KS vs Met vs Kombine
PKOS - KS vs KS+Met / Non IUI KS vs AI
4. 21.12.2013
4
KS vs AI
1 mg 100 mg
Optimal folikül çapı KS - Letrozol
Optimal folikül çapı KS - Letrozol
100mg 5 mg
PKOS- KS vs AI
7.5 mg 150 mg
PKOS, KS dirençli
5 mg x 5 g 2.5 mg x 10 g
KS dirençli PKOS – AI vs Met+KS
2.5 mg 1500 mg 2 ay ve sonra150 mg
5. 21.12.2013
5
Anovulatuar DSÖ II -KS vs FSH
• KS ile klinik gebelik üç siklus boyunca %33, 41
ve %26, FSH ile ilk siklusta %52.6 ve ikinci
siklusta %35.5.
• İlk siklusun sonunda gebelik oranı FSH ile OI
sonrası %30, KS ile OI %14.6 ( 95% CI 5.3–
25.8, P < 0.003).
• İlk iki siklus sonunda gebelik oranı FSH ile OI
sonrası %50.7%, KS ile OI %32.5 ( P <0.003).
• İlk üç siklus toplam gebelik oranı KS için
%41.2, FSH için %52.1 (P < 0.021).
• Üç siklus sonrası topla canlı doğum oranı KS
için %36.9, FSH için %47.4 (P < 0.031).
50 IU 75 IU 100 IU 125 IU
PKOS- KS vs Gnd
PKOS- KS vs Gnd
%43
%24
DSÖ II
Gebe kalma
şansı
75 IU 112.5 IU 150 IU 187.5 IU
DSÖ II Gebe kalma şansı
75 IU 112.5 IU 150 IU 187.5 IU
Anovulatuar DSÖ II – FSH eşik değeri
75 IU 112.5 IU 150 IU 187.5 IU
6. 21.12.2013
6
DSÖ II Anovulatuar (HP-FSH vs rFSH)
PKOS
FSH vs FSH+Anta
IUI için FSH doz nomogramı –
düzenli siklusu olan
N=159
KS / Gnd +IUI - Kaç defa?
Erkek subfertilitesi/ Açıklanamayan
KS vs rFSH (+ IUI) Açıklanamayan
Erkek subfertilitesi
7. 21.12.2013
7
EL - KS+ IUI
Açıklanamayan, erkek faktörü – LH
surge
100 mg 75 IU DD
Açıklanamayan
rFSH vs uFSH vs HMG (+ IUI )
Erkek subfertilitesi/ Açıklanamayan
HP-HMG vs rFSH (+IUI)
Erkek subfertilitesi/ Açıklanamayan
rFSH vs rFSH+ Anta (+IUI)
rFSH
Erkek subfertilitesi/ Açıklanamayan
Gnd vs Gnd + Anta (+IUI)
8. 21.12.2013
8
uFSH vs rFSH / OI+IUI GnRH - IUI
Açıklanamayan, erkek faktörü
rFSH 50-150 IU BA
Açıklanamayan, KS cevapsız
Günasırı 150 IU rFSH Letrozol 5 mg
Açıklanamayan infertilite
5 mg letrozol D3-7
150IU rFSH D4,6,8
5 mg letrozol D3-7
150IU rFSH D4,6,8
cetrorelix
Gebelik- rFSH vs rFSH + AI
9. 21.12.2013
9
KS ile ince EL -TMX Tmx + FSH altern.
40 mg D3-9 100 mg D3-7
> 40 Yaş
2.5 mg D3-7
50-100 IU > 40 Yaş
Eve götürülecek mesajlar -1
1. LH aktivitesi küçük foliküllerde atreziye neden olur
2. LH ile artmış oosit kalitesi – direk olmayan kanıt
3. LH aktivitesi foliküllerden östrojen yapımını arttırır
4. LH aktivitesi hastaları prematür progesteron
yükselmelerinden koruyabilir
Eve götürülecek mesajlar -2
1. rLH serum östradiolü arttırır
2. rLH ovaryen stimulasyon için gereken rFSH dozunu
azaltır
3. rLH 35 yaş ve üzerinde implantasyon ve klinik gebeliği
arttırır
4. rLH düşük ovaryen cevabı olanlarda canlı doğumu
arttırır
10. 21.12.2013
10
Eve götürülecek mesajlar -3
1. hCG LH etkisini sağlamak için kullanılabilir
2. Günde 50-200 IU uygun hCG dozudur
3. hCG eklenmesi FSH gerekesinimini azaltır
4. Önde giden folikül 12-14 mm iken hCG eklenmesi
klinik gebeliği arttırır
Eve götürülecek mesajlar -4
• Gonadotropin ile OI endikasyonları ;
– hipogonadotropik hipogonadism
– Klomifen –dirençli PKOS’tur.
• Anovulatuar kadınlarda tedavinin amacı;
– mono-ovulasyon sağlamaktır.
• Açıklanamayan veya hafif erkek faktörü infertilitesi
olan ovulatuar kadınlarda etkin tedavi;
– KOH + IUI dır.
• Gonadotropinlerin birbirine üstünlüğü yoktur ve
uriner veya rekombinant formlar benzer etkinliktedir
Eve götürülecek mesajlar -5
• HH olan kadınlarda küçük miktarda eksojen LH
optimal folikül gelişimi için gereklidir.
– Step-up rejimi bu grupta kullanılan tedavi protokolüdür
• PKOS olan kadınlarda ,
– Kronik düşük-doz step-up protokolü tercih edilir.
• Kesin iptal kriterleri ile yakın monitorizasyon
önerilmektedir
Eve götürülecek mesajlar -6
Çoğul Gebelik önlemek
I. İlk sikluslarda minimal stimulasyon
hMG başlamadan önce 3 siklus KS kullanılmalı
KS yerine tamoksifen veya aromataz inhibitörü (letrozole) kullanılmalı*
Minimal stimulasyon <75 IU hMG veya FSH ile başlanmalı
Stimulasyona siklusun 7. veya dominat folikül seçildikten sonra başlanmalı (≥10
mm) *
Geç proliferatif fazda FSH yerine hMG , veya hCG ya da rLH eklenmeli *
II. Çok fazla folikülün veya yüksek östrojen kons. olduğu sikluslar iptal
edilmeli
III. İptal yerine alternatifler
Fazla foliküllerin aspirasyonu *
IVF döndürme
Dikkatiniz için teşekkür ederim.