Ramon L. Ruiz, DMD, MD

• Medical Director, Pediatric Craniomaxillofacial Surgery
• Vice Chair, Department of Children? Surgery
• The Arnold Palmer Hospital for Children
• Associate Professor of Surgery,
• University of Central Florida College of Medicine
• Orlando, Florida

It is usually administered only briefly peripartum (Castaman 2006 menstruation tracker discount estradiol 2 mg visa, Gojnic 2005 pregnancy first trimester symptoms generic estradiol 1mg otc, Perez-Barrero 2003) breast cancer tattoo design generic 1mg estradiol visa. Clinically important vasopressin deficiency (diabetes insipidus) justifies the use of vasopressin or desmopressin during pregnancy women's health center of lebanon pa buy 1mg estradiol with visa. The use of the other vasopressin analogs is not grounds for a termination of pregnancy or for invasive diagnostic procedures menstruation lasting more than a week generic estradiol 2mg free shipping. The adaptation is an important prerequisite for normal embryonic and fetal development women's health vs fitness magazine 2mg estradiol mastercard, and also for an uncomplicated pregnancy. The fetal thyroid begins to function at the end of the third month of pregnancy (Burrow 1994). Before that, the embryo is exclusively dependent on the thyroid supply via the mother. In regions where iodine is in short supply, sufficient iodine should be assured even before pregnancy. In the case of severe iodine insufficiency, supplementation started after the second trimester may no longer counteract developmental abnormalities of the central nervous system (Xue-Yi 1994). When dietary iodine intake via iodized salt, iodized foods, and ocean fish is not reliable, supplementation in tablet form is necessary. In particular in relation to iodine deficiency, this has been understood for a long time. According to a recent study on 60 hypothyroid women (whose disease was only diagnosed after 12 weeks of pregnancy), hypothyroidism impaired the mental and motor capacities of their children, who were tested at the age of 2 years compared to children of euthyroid or only discrete hypothyroid women during pregnancy (Pop 2003). Haddow (1999) draws similar conclusions from his study on 60 children aged 7­9 years. Based on these results, hypofunction of the thyroid should be diagnosed and treated for the benefit of the developing unborn child. Regarding the risk of neonatal hypothyroidism after maternal thyrostatic therapy during pregnancy, see section 2. Pharmacology and toxicology Hormonally effective thyroid hormones are the L-forms of triiodothyronine (T3) and thyroxine (T4), which are only metabolically active in a free, non-protein-bound form. T3 is the biologically effective hormone with a short period of effectiveness, while T4 is a less effective prohormone or hormone depot that is deiodinated as needed to T3. However, in the case of fetal thyroid agenesis, there is substantial transfer of maternal thyroxine because of the high concentration gradient. Correction of maternal thyroid deficiency with these medications is not associated with abnormal fetal outcome. When thyroid hormones are indicated, thyroxine preparations should be prescribed because the mother retains control over the actual hormonal activity due to the conversion to triiodothyronine. As soon as pregnancy is confirmed, women with hypothyroidism should increase their levothyroxine dose by approximately 30%. During the second trimester a further dose increase is necessary, to an approximately 40­50% higher dose compared to the prepregnancy situation. Serum thyrotropin levels should be monitored in order to find the correct individual thyroxine dose. During thyrostatic therapy, thyroid hormones should not be given in addition because the need for placenta-permeable thyrostatics is increased as a result. A recently published prospective study on 115 pregnant women reports a much higher rate of 12. They inhibit the synthesis of T3 and T4 by blocking the organification of iodine and the coupling of iodothyronine residues. Propylthiouracil has a higher protein-binding than the other thyrostatic substances, and presumably a lower placental transfer. However, no significant differences in neonatal thyroid function were found by several authors. Not all hypothyroid neonates demonstrated goiter directly after birth; some were noted only at the screening control 2 weeks later. Individual case descriptions led to the hypothesis that methimazole could cause skin defects (aplasia cutis) in the fetus and other teratogenic effects like choanal atresia, esophagus atresia, tracheal esophageal fistula, hypoplastic nipples, facial dysmorphism, and psychomotoric developmental delay (Nakamura 2005, Barbero 2004, Karg 2004, Ferraris 2003, Karlsson 2002, Clementi 1999, Wilson 1998, Hall 1997, Johnsson 1997, Vogt 1995). Foulds (2005) reviewed all the published cases and concluded that there are 16 reports regarding infants or fetuses exposed to methimazol/thiamazol in first trimester, showing a similar pattern of malformations. However, multiple case collections have indicated neither morphologic developmental disturbances (Wing 1994) nor effects on the size or function of the thyroid or on the physical and intellectual development of children as a result of prenatal exposure to propylthiouracil or methimazole (Eisenstein 1992, Messer 1990). In a prospective multicenter case-control study on the outcome of 204 methimazole-exposed pregnancies, no significant total major malformation rate was reported. However, among the eight reported birth defects, there was one case of choanal atresia and one case of esophagus atresia (di Gianantonio 2001). To date, thyrostatic drugs during pregnancy do not appear to induce a significant increase in the rate of major malformation. However, methimazole can cause a rare embryopathy with a frequency of 1:1000 to 1:10 000 exposed fetuses (Cooper 2002, Diav-Citrin 2002). Carefully adjusted thyrostatic therapy with antithyroid medications is unlikely to lead to fetal goiter in pregnancy. Earlier goiter-caused obstructions of the airways and interference with the birth process were described as a result of therapy with thyrostatics, in combination, to some degree, with high levels of iodine or with thyroid hormones. Propylthiouracil is the thyrostatic drug of choice in pregnancy, especially in the first trimester. Thiamazole (methimazole) and carbimazole are to be considered second-choice drugs. The dose can be kept to a minimum by maintaining maternal thyroid status a little above normal. Thyrostatic therapy should not be combined with thyroxine supplementation, because this 392 2. The screening of thyroid parameters of the newborn is absolutely necessary, and this is compulsory in many countries. A second evaluation of the thyroid status should be performed 2 weeks after birth in the case of intrauterine exposure. Mild symptoms of hyperthyroidism with borderline laboratory parameters can be treated symptomatically without thyrostatics, for example with -receptor blockers such as propranolol or metoprolol. If thiamazole (methimazole) or carbimazole has been used during organogenesis, a detailed anatomical ultrasound examination is recommended. In cases of severe thyrotoxicosis, thyroidectomy may be indicated ­ even during pregnancy. Corticosteroids act on the carbohydrate, protein, and lipid metabolism; the maintenance of fluid and electrolyte balance; and the preservation of the normal function of the cardiovascular and immune systems, the kidneys, the skeletal muscle, and the endocrine and nervous systems. In addition, corticosteroids allow the organism to resist stressful circumstances such as noxious stimuli and environmental changes. The effects of glucocorticoids are mediated by genomic and non-genomic mechanisms (Czock 2005). Corticosteroids interact with specific receptor proteins in target tissues to regulate the expression of the corticosteroid-responsive genes, modifying the levels of proteins synthesized by these target tissues. The genomic mechanism includes activation of the cytosolic glucocorticoid receptors that lead to activation or repression of protein synthesis, including cytokines, chemokines, inflammatory enzymes, and adhesion molecules, which modify the inflammation and immune response mechanisms (Czock 2005). However, inhibition of other transcription factors may account for the deleterious effects of glucocorticoids, such as adrenal suppression and osteoporosis (Roumestan 2004). In contrast with these genomic effects, some actions of corticosteroids can be immediate and mediated by membrane-bound receptors (Christ 1999). The corticosteroids are grouped according to their capacity for Na retention, their effects on carbohydrate metabolism, and their anti-inflammatory effects. Thus, glucocorticoids have pleoiotropic effects and are used in clinical practice in (as well as replacement therapy in cases of adrenal insufficiency) treating diverse diseases such as inflammatory rheumatic disorders, asthma, autoimmune diseases (systemic lupus erythematosus and others), acute kidney transplant rejection, and allergic and skin diseases. In pregnant women at risk for preterm birth, corticosteroids are also used for the induction of lung maturity. High doses of daily glucocorticoids are usually required in patients with severe diseases involving major organs, whereas alternate-day regimens may be used in patients with less aggressive disease. Intravenous glucocorticoids (pulse therapy) are frequently used to initiate therapy in patients with rapidly progressive, inmunologically mediated diseases (Boumpas 1993). All systemic glucocorticoids cross the placenta to some degree after administration to the mother (Levitz 1978), but the fetal serum concentrations can vary according to the glucocorticoid used. Betamethasone and dexamethasone cross the placenta well (this is the reason why they have been traditionally used by obstetricians to enhance fetal lung maturation), whereas prednisone, methylprednisolone, and prednisolone appear to cross the placenta only to a small extent, and may for this reason be preferred for the treatment of maternal illness. Teratogenic effects the maternal treatment with glucocorticosteroids during the first trimester of pregnancy does not seem to represent a major teratogenic risk in humans. In spite of children with congenital defects being described in several case reports of women treated during the first trimester of pregnancy for a wide variety of maternal diseases, there has been no consistent pattern of defects leading to the suggestion of a causal drug effect. Likewise, some prospective epidemiological studies have been published in which there was no evidence to suggest a significant increased risk of congenital malformations 2 Pregnancy 2. Nevertheless, several epidemiological studies have associated maternal treatment with glucocorticoids with an increased risk of oral clefts (Kдllйn 2003, Pradat 2003, Carmichael 1999, Rodrнguez-Pinilla 1998). Moreover, in one prospective negative study the authors include a meta-analysis of the epidemiological studies published so far that concludes that therapeutic doses of corticosteroids in humans increase the risk of oral clefts by an order of 3. The association between glucocorticoids and oral clefts has also been discussed following maternal use of topical corticosteroid during pregnancy (Edwards 2003, Czeizel 1997), although Czeizel discounted this finding because the mothers stopped the medication after the first month of gestation. The results of Edwards (2003) should be interpreted with caution because, although statistically significant, the confidence interval was extremely wide (1. Thus, taking into consideration the existing data, it is reasonable to conclude that there is no evidence of a significant increase in the basal risk for congenital anomalies, although a possible association with clefts cannot be excluded. Fetal toxicity There is still concern regarding intrauterine glucocorticoid exposure as the origin of some adult diseases. Conditions that are suspected of having been programmed before birth include hypertension, diabetes, coronary heart disease, and stroke (Rennick 2006, Newnham 2001, Challis 1999). Thus, the long-term effects of fetal glucocorticoids (especially dexamethasone) in humans are unclear, and whether they have a role in programming the individual for adult degenerative diseases remains to be studied. Some clinical studies have suggested a possible relationship between antenatal exposure to prednisone and other corticosteroids as a treatment for maternal diseases, and an increased incidence of fetal growth restriction. Nevertheless, the effect of the corticosteroids in these cases of intrauterine growth retardation is uncertain, and the underlying maternal disease (often autoimmunity diseases, renal transplantation, asthma) as well as the concomitance medications (such as immunosuppressant drugs) could be playing a predominant role. Depending on dose and the treatment interval, adrenal cortical insufficiency in the newborn babies may occur. Antenatal exposure to betamethasone but not dexamethasone has been associated with a decreased risk of cystic periventricular leukomalacia among very premature infants (Baud 1999). Nevertheless, multiple works have been published showing adverse effects on the fetus after the administration of two or more complete courses, such as decreased fetal growth (Thorp 2002), reduction in birth head circumference (Thorp 2002), transient hypertrophic cardiomyopathy (Yunis 1999), increased mortality (Banks 1999), prolonged adrenal suppression, increased risk of early-onset neonatal sepsis, and increased perinatal mortality. Also, adverse effects have been described in the pregnant woman exposed to multiple courses, such as a higher incidence of postpartum endometritis (Abbasi 2000). Recently, a work has been published which analyzed a sample of 29 557 singleton live-born infants without congenital defects to study the effects on fetal growth of antenatal corticosteroid treatment used to promote fetal lung maturation (Rodrнguez-Pinilla 2006). In this work, and controlling for potential confounder factors (year of birth, maternal age, gestational age, parity, maternal smoking and/or alcohol consumption, gestational diabetes, nongestational diabetes, and other maternal chronic diseases), the exposure to more than one course of antenatal corticosteroids resulted in a significant reduction in birth weight, length, and head circumference in singleton preterm infants. Exposure to just one course of antenatal corticosteroids also significantly reduced the weight (by 17%; p 0. This correlation between the administered dose and the weight of the newborn children had been previously proven in animal experiments (Ikegami 1997). In addition, the significant interaction found between the treatment and the gestational age at birth indicated that the effect of corticosteroids is enhanced in the most premature babies (RodriguezPinilla 2006). Also, exposure to a single course has not been associated with later obvious adverse effects on growth, intellectual and motor development, school achievement, social-emotional functioning, and lung function in the 10­14-year-olds studied (Doyle 2000, Schmand 1990). Dalziel (2005) followed up, at age 30 years, 534 individuals whose mothers had participated in a double-blind, placebo-controlled, randomized trial of antenatal betamethasone for the prevention of neonatal respiratory distress syndrome. There were no differences between the two groups in body size, blood lipids, blood pressure, plasma cortisol, prevalence of diabetes, or history of cardiovascular disease. Only after a glucose tolerance test were the prenatally betamethasoneexposed identified as having higher plasma insulin concentrations. These facts, together with the evidence that the administration of a single course is effective to prevent the neonatal respiratory distress syndrome, justify its administration in the pregnant woman at risk of preterm delivery. Nevertheless, a recently published randomized controlled trial supported the use of repeat doses of corticosteroids (betamethasone), 7 or more days after the initial course, in women who remain at risk of very preterm birth (Crowther 2006). Beyond the thirty-fourth week of pregnancy, support of lung maturation is usually not necessary. On the other hand, placebo-controlled studies with mice exposed to corticosteroids during pregnancy have shown that betamethasone has less detrimental effects than does dexamethasone on the neurobehavioral development of the offspring, and is more potent in accelerating fetal lung maturity (Christensen 1997, Rayburn 1997). These experimental results, together with clinical studies in premature infants, suggest that betamethasone must be the preferred corticosteroid for use in women at risk of preterm delivery (Groneck 2001, Baud 1999). In maternal inflammatory diseases, the benefits of glucocorticoid therapy on the maternal health can be offset by the low risk to the fetus, as long as there 2. Beyond its use during the first trimester, a high-resolution echocardiography could be recommended, especially for the diagnosis of oral clefts. In maternal asthma and allergic diseases, pregnancy is not considered to be a contraindication for the continuation of corticosteroids therapy. Therefore, risk­benefit consideration still favors the use of oral or inhaled corticosteroids during pregnancy when indicated for the treatment for asthma. The use of betamethasone for this indication may be of advantage compared to dexamethasone. A poor glycemic control in pregestational diabetes, as measured by glycosylated hemoglobin (HbA1c 6. HbA1c is a parameter for the blood glucose concentration of the last 120 days, the survival time of erythrocytes; it can also be referred to as the "blood sugar memory". The higher the concentration of HbA1c, the higher the statistically confirmed rate of malformations: an HbA1c of 8. The most common birth defects are anomalies of the spine and extremities, of the heart and circulatory system, and neural tube defects.

Diseases

• Billet Bear syndrome
• Hemangioendothelioma
• Holoacardius amorphus
• Mucopolysaccharidosis type II Hunter syndrome- mild form
• Fanconi syndrome
• Pulmonary hypertension
• Familial m Familial w
• Amnesia, drug-induced
• Bindewald Ulmer Muller syndrome

A good example of this can be found in Nigeria breast cancer 3 day philadelphia buy 1 mg estradiol overnight delivery, where the decision of the Anglican Mission (Church Missionary Society) in 1883 to favour African names for converts created a sensation menopause symptoms after hysterectomy generic estradiol 2 mg overnight delivery. Some families left the Anglican community when the local pastor refused to baptise children with other than African names menstruation breastfeeding order estradiol 2mg, and many threw off these African names immediately after the baptism breast cancer cupcakes discount 1mg estradiol with amex. Some of them defended foreign names because they could protect the converts from being enslaved womens health uiuc generic 1mg estradiol with mastercard, and because they created national unity among Christians coming from different tribes women's health clinic somerset ky purchase 2mg estradiol otc. He then bore the combined names of "Patrick Owusu Benefo" only one of which was recognized in his home environment! The other are school or church imposed names, which made him lose his own identity in the bizarre environment of the school and the church. At the western dominated school and church he had one set of names, while in his own cultural and traditional setting, he had a completely different set of names. Many urbanised and educated Africans also chose to give exclusively European names to their children. But the baptismal name was always an additional name, coming some time later, at times years after the naming ceremony. Moreover, this ceremony was an out-of-church affair of the extended family, well beyond the influence of the missionary church. In this process, European names have increasingly lost favour, and churches have come to accept African baptismal names as well. In Nigeria, the cultural nationalists achieved their first successes at the end of the 19th century, and some educated Africans assumed African names at that time. One of the leading figures in the nationalist movement, for example, changed his name Joseph Pythagoras Haastrup to Ademuyiwa Haastrup. The most important factor that made them decide to assume African names was that they saw themselves bearing meaningless names in a society that attached a great deal of importance to names. Despite these early name changes, European names became increasingly popular in Nigeria at the beginning of the 20th century, and it was only in the 1940s that there was a tendency to use African names again (Wieschhoff 1941, p. In Tanzania, where the cultural renaissance took place much later, mainly in the 1960s and 1970s, the reasons for name changes seem to have been more or less similar. African names were adopted to get rid of "one aspect of colonial mentality and heritage" and to show other people that the name-bearers were true Tanzanians or Africans. In some newly independent African countries, indigenous names were even made compulsory by their African leaders. Probably the most striking example comes from Zaпre, where President Mobutu Sese Seko insisted on the Africanisation of personal names and threatened to prosecute Catholic priests who refused to baptise people with African names in 1972. Many European elements were retained and new ones adopted into African naming systems. In different parts of Africa, different kinds of traditional names were used for this purpose. Among the Hereros, the name of the father or an illustrious ancestor serves as a surname (Otto 1985, p. This is a general practice in many other African cultures as well (Madubuike 1976, p. The surname system has often been considered alien to African cultures, and it has also been criticised strongly. Ayandele argues that the people who adopted the surname system in Nigeria actually made a cultural synthesis which includes both African and European elements. His analysis could well be applied to other peoples in Africa: They retained parts of indigenous culture that were deemed valuable and borrowed judiciously from the European civilization they so much execrated. Realizing that complete cultural independence was impossible, they evolved a new synthesis which was neither reactionary traditionalism nor Europeanimitative but sufficiently African in appearance to satisfy their race-pride and sentiment. Adoption of surnames was compatible with British law of property and inheritance in the Lagos colony which they had accepted without questioning. It fitted in well with the individualism towards which each Christian family was groping ­ the idea of a man, his wife and children in place of the extended family. Roughly speaking, the first stage is characterised by traditional naming and name uniqueness, the second by the popularity of biblical names, the third by the increased use of other European names, and the fourth by the revival of African names: 1. The period of increased Westernization (influence of education, industrialization, urbanization, etc. The period of "Black Consciousness" (1950­1982) As Dickens wrote her thesis in 1985, her presentation naturally ends in the 1980s. Because of this, a fifth stage needs to be added to her list: the post-apartheid period in South Africa, which started in 1994. According to him, the development from a system of a single name to that of two given names in anglophone southern Africa, i. Even if colonial names are today rejected, the Western pattern of two given names and a surname is retained. South African onomasticians have also found other interesting trends in urban name-giving. Firstly, there is a clear shift from negative to positive naming in indigenous names, which means that traditional names which include negative social comments are disappearing, whereas names 63 Personal Names and Cultural Change reflecting positive emotions have become more popular. These changes have been explained by the nuclearisation of the family in the urban context and the important role of the church in the social life of many people. There are also signs of the weakening of ethnic boundaries in personal naming: a Zulu child may receive a Sotho name, for example (Suzman 1994, p. It seems that more and more people also choose names which they find pleasant-sounding, which is a new phenomenon in African personal naming (De Klerk & Bosch 1995, p. It is reasonable to suggest that similar developments do and will characterise name-giving in other African societies, which are experiencing rapid urbanisation as well, even if they have not been researched as systematically as those in the South(ern) African context. All in all, it seems that African personal naming has come to resemble modern European naming in many respects, despite the fact that the names themselves are increasingly African. On the other hand, the criterion of name meaningfulness continues to distinguish these two systems (Herbert & Bogatsu 1990, p. Vermeersch (1977) presents an analysis of the definitions Kroeber and Kluckhohn took up, as well as of some later publications on this subject. On the other hand, many anthropologists have given up formulating such definitions. In order to show what culture is, they simply refer to examples of cultural behaviour. Usually, anthropologists see that cultures change internally by two main processes: innovation and invention. He pointed out that inventions, social order and intellectual life are not always equally developed in a society: there are people whose material culture is rather poor, but who have a highly complex social organisation, etc. As the steps of invention do not always follow in the same order and there are often important gaps in this development, Boas (op. The term acculturation has been used by American anthropologists, whereas the British have traditionally preferred the term culture contact. For example, material objects whose use will save time and human energy are easily adopted. Therefore, manufactured clothes tend to replace home-made ones everywhere, and metal tools and weapons seldom fail to replace articles made of stone or wood. It is something much bigger and more significant than the speech of any individual person; it is a cumulative product of millions of individuals representing preceding generations. Usually these typologies list the possible consequences of such contacts, varying from minor effects on the vocabulary to the formation of new types of language. It is important to note that philosophers often look at personal names from a different viewpoint than linguists or onomasticians, and there has not been much coordination between these theories. He points out that an onomastic item could well be called a name under most or all of these circumstances. On all these levels, and normally on several or even all of them simultaneously, the name functions in the speech act of identification which is the prerequisite for the speech act of recognition. For example, the Finnish lexicon is considered to contain only one personal name Heikki, even if there are thousands of men in Finland who have this name. On the other hand, the lexicon contains as many place names as there are places named, even if some of these names are similar in form. For this reason, it has been impossible to form a definition of a name which would cover both toponyms and anthroponyms. However, according to present understanding, there are no names that are not proper. This view was already presented in the Middle Ages by William of Conches, who stated that the proper name refers without qualitative meaning to an individual substance (Summerell 1995, p. The verb name is an exercitive, which means that "it is a decision that something is to be so". There have been a number of other attempts to describe the systematic nature of naming systems. Blanбr 1996; Seibicke 1996; Van Langendonck 1995), but these turned out to be less helpful for this study. As he sees it, a byname ­ in European naming systems ­ denotes all individual personal names that are not forenames (first names, Christian names). Kohlheim (1977b) applies the innovation theory to the study of the diffusion of onomastic innovations, such as the practice of naming children after saints in Medieval Europe. He analyses the stages of the onomastic diffusion process and the roles of social status and fashion in the acceptance of new personal names and name-giving practices. For example, gender is marked morphologically in the Romance personal naming systems. These "system-like features" strengthen the relationships between the elements of the system and thereby stabilise its boundaries. It is important to note that one naming system may also be influenced by another in cases where there are no deeper linguistic contacts between the two languages in question. For example, the influence of English on personal names in Brasil is significant, even if the English language has not had much influence on the Portuguese language (Thonus 1991, p. In this study, we shall for example see how some Finnish missionaries have given their children Ambo names. It is interesting to compare this list with the semantic categories of traditional Welsh names presented by Morgan (1995, p. Later on, however, as the names became established as names, and as they were repeated, their original meaning was no longer taken literally. It also seems that the original meaning of names was sometimes not obvious and had to be pointed out by scholars as it does today. In his pioneering study on pre-Christian personal names in Finland, Forsman (1894, p. In more modern times it has become customary for popes to adopt new names after their election. The latter group consists of names which include a confession or reflect trust, hope or gratitude. However, there are also many personal names in the Old Testament other than Hebrew ones, and the names in the New Testament are not exclusively of Greek origin either (Jenni 1996, p. In this study, the term Christian name is primarily used for biblical names and names of saints and other religious figures. In some cases, it is also used to refer to semantically transparent names which have religious meanings. It is impossible to give exact information about the spread of Christian personal names in Finland because of the lack of historical documents. The names of the rural population began to appear systematically in written documents in the 16th century only. National patron saints have also had a strong influence on personal naming in many countries: St. Altogether, the calendars of the saints included names of Church fathers, martyrs, mystics, ascetics, founders of religious orders, local saints, etc. In Germany, Nikolaus was the patron saint of seamen and tradesmen, Hubertus that of hunters, Lukas of painters, etc. The eldest sons, who were the potential heirs to the throne, received Scandinavian names. The most popular names for women were Else, Gese, Alke, Margareta, Styne, Mette, Katharina, Gerdrut, Kunne and Fenne, and they were carried by 76 per cent of all women. At the end of the 16th century, 22 per cent of all men in Lippstadt were named Johann, and in the mid 18th century, 48 per cent of them had this name. Many Germanic personal names survived in the Middle Ages also because they were used by noble families (Wilson 1998, p. For example, old German and Scandinavian personal names were borrowed by the Finns in the early Middle Ages from traders and craftsmen. These hypocoristic name forms indicated family relationships in the same way as repetition of name elements in the old Germanic naming systems had done (Wilson 1998, p. A byname can be understood as a name which is added to another name already borne by the name-bearer (Neethling 1994, p. Altogether, there are many terms for different kinds of bynames in European languages. Often terms which look similar in meaning, may also cover different concepts in different languages. In English, for example, one can find the terms nickname, call name, hypocorism, petname, patronymic, surname, family name and last name, in German Beiname, Rufname, Spottname, Kosename, Spitzname, Zuname, Familienname and Geschlechtsname, in Afrikaans bynaam, noemnaam, roepnaam, familienaam and van, in Swedish tillnamn, binamn, smeknamn, цknamn, vedernamn, patronym and slдktnamn, and in Finnish lisдnimi, lempinimi, kutsumanimi, patronyymi and sukunimi. Similarly, African languages have various terms for these names, which are often difficult to translate into European languages. In written documents, it is often difficult to draw a line between a "real" byname and an occasional note of the recorder which aimed to individualise the person (Fleischer 1968, p. Usually, onomasticians talk about surnames only after they have been in use in two or three generations (Seibicke 1982, p. However, it might be justified to use this term also in cases where a person has consciously adopted for him/herself a surname, even if it has not yet been in use for two or more generations.

Mathematically speaking women's health clinic newark ohio estradiol 2 mg cheap, a fully breastfed baby would receive up to 11% of a maternal weight-related dosage womens health 30s order 1 mg estradiol fast delivery. There is no special information on milk transfer with chlormadinon women's health and wellness issues estradiol 1mg free shipping, dydrogestone pregnancy chinese calendar gender buy estradiol 1mg lowest price, gestonorone women's health clinic lexington ky purchase estradiol 1 mg on-line, gestoden menopause kit joke generic 2 mg estradiol mastercard, hydroxyprogesterone, levonorgestrel, medrogestone, and norgestimate. When used in oral contraceptive preparations, in gestagencontaining intrauterine pessaries, and in the "morning-after pill", these substances can probably be evaluated similarly to the abovementioned contraceptives. Higher-dosed gestagen preparations used for other indications have not been studied with respect to their kinetics, but there are unlikely to be many indications for their use during breastfeeding. In his literature review, Truitt (2003) could not find any differences between gestagene monotherapy and combination pills regarding the amount and quality of milk production. However, he underlined methodological problems in many of the evaluated studies that limited his conclusions. Children with levonorgestrel had slightly more mild respiratory tract infections, eye infections, and skin problems during the first year of life. In the so-called developing world, much more "birth control" is attributed to breastfeeding than to the other family planning measures (Hanson 1994). Pure gestagen preparations (mini-pills) are the oral contraceptive of choice during breastfeeding. If the mother does not tolerate them, then the low-dosage combination "pills" (ethinylestradiol plus gestagen), or gestagen depot preparations, are acceptable. There is no preparation among the well-established hormonal contraceptives which requires an interruption of breastfeeding. Accidental intake of a single dose does not require an interruption in breastfeeding. The more common daily intake of 2 mg of cyproterone acetate for acne therapy has not yet been studied. Other antiandrogens, such as bicalutamide and flutamide, and antiestrogen-acting substances, such as aminoglutethimide, anastrozole, formestan, raloxifene, and tamoxifen, as well as the sexhormone inhibitors danazol and tibolone, have practically no role during breastfeeding and have also not been studied. There are also no data on clomiphene and the progesterone antagonist mifepristone. In so far as its (accidental) use during breastfeeding happens at all, a toxic effect on the infant should not be expected due to the brief exposure. Accidental intake of a single dose does not require an interruption of breastfeeding. After birth, other pharmaceuticals are used for uterine involution so that therapy during breastfeeding for obstetrical indications is not common. Prostaglandin derivatives have short half-lives ranging from a few seconds to 20­40 minutes at maximum. Both milk-promoting and milk-inhibiting effects have been noted with the various prostaglandins. In a study of 20 women with postpartum uterine atony, either 200 g misoprostol or 250 g methylergometrine were administered orally. The maximum misoprostol concentration in milk was reached at 1 hour, with a half-life of 0. Considering the maximum concentration in milk, the relative dose for misoprostol was 0. There is no indication yet of negative effects of prostaglandins in the breastfed infant. Prostaglandins should only be used for compelling treatment indications during breastfeeding. If severe glaucoma requires local treatment with latanoprost, breastfeeding can continue provided there is careful observation of the baby. Single doses of other prostaglandins, such as misoprostol for uterine atony, do not require any limitation of breastfeeding. Thyroid function in breast-fed infants whose mothers take high doses of methimazole. Intellectual development and thyroid function in children who were breast-fed by thyrotoxic mothers taking methimazole. Transfer of drospirenone to breast milk after a single oral administration of 3 mg drospirenone + 30 microg ethinylestradiol to healthy lactating women. Increased recall rate at screening for congenital hypothyroidism in breast fed infants born to iodine overloaded mothers. Methimazole pharmacology in man: studies using a newly developed radioimmunoassay for methimazole. Untersuchungen ьber den Ьbergang des aktiven Agens des Mutterkorns in die Milch stillender Mьtter. Luteinizing hormone releasing hormone agonist for contraception in breast-feeding women. Growth, motor, and social development in breastand formula-fed infants of metformin-treated women with polycystic ovary syndrome. Breast feeding is a natural contraceptive and prevents disease and death in infants, linking infant mortality and birth rates. Myocardial infarction post-partum in patients taking bromocriptine for the prevention of breast engorgement. Transient hypothyroidism in a breastfed infant after maternal use of iodoform gauze. Thyroid function in wholly breastfeeding infants whose mothers take high doses of propylthiouracil. The treatment of prolactinomas during pregnancy and the lactation period . Health and growth of infants breastfed by Norplant contraceptive implants users: a six-year follow-up study. Iodine concentration in the breast milk of mothers of premature infants . The quantity of thyroid hormone in human milk is too low to influence plasma thyroid hormone levels in the very preterm infant. Oils, emollients, creams, and beauty lotions generally act locally on the skin, and do not contain active principles. There are, however, skin preparations that contain potent active chemicals, including liniments and treatments for acne, psoriasis, and other skin diseases. It then becomes a matter of dose, including the concentration of the active ingredient, the surface area covered, the thickness of skin in the area treated, and the treatment interval. If treatment involves a large area of the skin over a long period, then the absorption and 4. Hair preparations, cosmetics, and sunscreens can be used with caution while lactating. Here, the advice on systemic use can serve as orientation (see, for instance, iodine and salicylates). When the breast needs to be treated externally, it should be cleaned before the baby is fed. However, hypersensitization as well as toxic symptoms have not been demonstrated as yet. This does not change the obligation to reduce dermal applications to those that are absolutely essential. It is recommended that bleaching, dying, straightening or curling be done by a professional to reduce the exposure of the lactating woman. The scalp is thick and absorbs poorly, so these chemicals can be used carefully if the hair is rinsed thoroughly. No studies have been done to measure the chemicals in the milk, but it is highly unlikely that much is absorbed and that any reaches the milk. Maternal use of sunscreen while lactating is considered safe when mother relies on shading to minimize direct sun exposure as well. Herbal preparations which also contain chrysanthemums can cause allergic reaction in individuals who are allergic to this family of plants (chrysanthemums, ragweed, and Echinacea are all members of the Composite family). In difficult cases which no longer respond to permethrin, a prescription for lindane 1% may be given; this must be rinsed off within 4 minutes. It is highly toxic to the central nervous system and is contraindicated in children weighing under 50 kg. Oral absorption is more rapid than dermal, so application is contraindicated during lactation. It can cause respiratory depression, and should not be used in a child under 2 years of age. Used carefully and following the instructions for rinsing, this should be safe during lactation as long as the mother develops no symptoms (lacrimation, salivation, shortness of breath) and the infant is not exposed directly. Suffocation of lice by application of occlusive agents such as coconut oil, petroleum jelly, olive oil, or full-fat mayonnaise is reported to be successful, and carries no toxicity or risk during lactation. Scabies Medications for scabies include the preparations for lice, but they must be applied over a wide area of skin (usually the entire body). Permethrin cream (5%) is recommended, including during pregnancy and lactation, in spite of the large amount required, but not for use in children under 2 months of age. Benzylbenzoate and allethrin, a synthetic pyrethroid, are also effective and are not absorbed intradermally. Lindane, as mentioned previously, poses a theoretical risk which is amplified when the compound is used for scabies, based on the area exposed (dose). Lindane is found in the environment, and has been found in maternal milk in environmental screenings. This is 60 times greater than the baseline measured from environmental contamination. Lice infestation should be treated with coconut oil or pyrethrum extract/permethrin, and scabies with crotamiton or benzyl benzoate. Tretinoin is a vitamin A congener that is used topically and is poorly absorbed through the skin. The risk of use during lactation has not been reported, but will be low because of lack of absorption. The retinoid isotretinoin, however, which is taken orally, could appear in the milk as it is absorbed orally, has a small volume of distribution, and is lipid-soluble. With acitretin, which has supplanted etretinate in psoriasis therapy, about 1% of the maternal weightrelated dosage is passed to the fully breastfed infant. Minocycline, now available in an extended-release oral preparation (Saladyn), is effective in moderate to severe acne (Shalita 2006). The extended-release form reduces the incidence of vestibular side effects and allows the lowest possible effective dose (1 mg/kg). Minocycline is a broad-spectrum tetracycline antibiotic capable of causing dental staining and reduced bone growth in children, though. It binds to milk calcium and is more effectively absorbed than previous tetracyclines. In the short term (less than 2 weeks) it is probably tolerable, but chronic use would be contraindicated during lactation. Minocycline has been measured in human milk, although it was not found in the plasma of breastfeeding infants whose mothers took 500 mg orally four times a day. There is no published experience with the external use of tazarotene, calcipotriol, dithranol (sometimes with salicylic acid), urea, and coal tar preparations. Systemic therapy with retinoids should not be undertaken during breastfeeding because of the toxic potential and the long halflife. This also applies to external use of coal tar preparations because of their mutagenic and carcinogenic potential. The other medications mentioned are acceptable unless significant absorption must be assumed due to a large area of application and regular use, and/or with application under occlusive bandages. However, pimecrolimos treatment is well-tolerated in young infants from 2 months (Kapp 2002). There were no symptoms observed in the breastfed infants of seven treated mothers (Armanti 2003). Essential oils may be used externally during lactation, when direct contact of the child with the oil is avoided ­ again, treated breasts should be washed before suckling the infant. However, the total dose of active principal could be calculated and may well be below the level of concern when given by drops to the eye or ear. Eye treatments include dilators, constrictors, antibiotics, antiinflammatories, and artificial tears. Medication by drops in the eye, ear, and nose are usually compatible with breastfeeding. Ophthalmic atropine can be an issue if used chronically, as it may decrease milk production. Preparations for the eyes or ears that contain chloramphenicol, quinolines, and streptomycin should be avoided. Antibiotics and antifungals are commonly used in the form of suppositories and douches. If the compound can be used systematically for other infections, it is safe via the vagina. Of considerable concern is the use of iodine preparations, including providone-iodine suppositories or douching. Atropine is absorbed from the eye quickly, peaks systemically within an hour and clears in less than 24 hours (half-life 4 hours). Atropine does dry secretions, so continued use has the potential for reducing milk production. The dose that is absorbed systemically is minimal, and well below the acceptable daily intake for a lactating woman. There were no symptoms observed in a breastfed infant whose mother was treated with eye drops containing timolol, dipivefrin, and dorzolamid, and who occasionally took acetazolamid orally (Johnson 2001).

When epilepsy is well-controlled with valproic acid pregnancy nausea remedies buy 2 mg estradiol, if no possibility exists to replace it by one of the novel anticonvulsants menstruation in the bible purchase estradiol 1mg on line, and if the woman wants to become pregnant womens health fitness us diet purchase 1 mg estradiol overnight delivery, therapy may be continued during pregnancy menstruation 4 weeks postpartum buy estradiol 2 mg lowest price. The outcome was uneventful in four cases breast cancer medication order estradiol 1 mg line, two pregnancies were terminated breast cancer donation estradiol 2 mg on line, and one was spontaneously aborted. As is the case with other anticonvulsants, especially with combination therapies, an increased rate of birth defects is to be expected. Morrow (2006) reported 31 informative pregnancy outcomes with exposure to gabapentin monotherapy, and observed 1 congenital malformation (ventriculoseptal defect). Moreover, 51 pregnancies were reported to the company (Montouris 2003), and a similar number of cases was gathered in a prescription study (Wilton 2002) performed within the Australian Epilepsy Register. Four different birth defects were observed among these prospective and retrospective data, all with polytherapy including gabapentin. However, an expanded prenatal diagnosis with an -fetoprotein determination in maternal blood around the sixteenth week of pregnancy and detailed fetal ultrasound in the second trimester should be conducted to rule out major disturbances of structural development, especially neural tube defects. The woman should be informed of the risks for both structural and behavioural anomalies. Available human and experimental data do not indicate a substantial teratogenic risk of gabapentin monotherapy. Gabapentin should not be used for treatment of non-epileptic diseases (neuropathic pain, psychiatric diseases) when pregnancy cannot be ruled out. Lamotrigine seems to increase the probability of getting pregnant compared to valproate: in a study by Isojдrvi (1998), lamotrigine was substituted for valproate because of frequent occurrence of polycystic ovaries and hyperandrogenism associated with weight gain and hyperinsulinemia in women taking valproate. Twelve such patients were observed for 12 months, and the total number of polycystic ovaries in these women decreased from 20 during valproate medication to 11, 1 year after replacing valproate with lamotrigine. Lamotrigine also seems to interact with hormonal contraception: Sabers (2001) reported seven cases in which the plasma levels of lamotrigine were significantly decreased by oral contraceptives (mean 49%, range 41­64%). The interaction was of clinical relevance in most of the patients, who either experienced increased seizure frequency/recurrence of seizures after oral contraceptives had been added, or adverse effects following withdrawal of oral contraceptives. Such a seizure increase was described in nine pregnancies on lamotrigine monotherapy by de Haan (2004); this was probably related to a gradual decline of the drug level-to-dose ratio to 40% of baseline. Case reports are available on a small number of successful pregnancies with exposure to lamotrigine in monotherapy (Cissoko 2002, Jovic 1999). With respect to newer antiepileptics in pregnancy, most documented experience exists for lamotrigine. If comparable therapeutic efficacy can be assumed, lamotrigine may be used instead of a classic 2. The available (but still unpublished) prospective case observations of the manufacturer on 989 pregnancies with exposure to lamotrigine in monotherapy during the first trimester do not indicate a teratogenic risk in human beings: 26 major malformations were observed among 908 eligible outcomes (2. No specific malformation was associated with the drug, but an increased rate of major birth defects was seen in cases of combination with valproic acid (15 of 133 11. However, no dose-effect at least at daily doses up to 400 mg was found in the registry of the manufacturer (GlaxoSmithKline 2007). Sabers (2004) reported 1 major birth defect among 51 pregnancies documented in a Danish registry. Among the major malformations were 5 oral clefts: 2 cleft lip and palate (doses: 400 mg and 125 mg), and 3 cleft palate (doses: 300, 500, 100 mg). Data from other registries (GlaxoSmithKline, Swedish and Australian registries) show that 4 newborns had clefts among 1623 exposed ­ i. This constitutes a signal for a potential risk of cleft in case of in utero exposure to lamotrigine, but no clear conclusion can be drawn because the rate in the unexposed group was particularly low, because the cleft rate is highly variable among populations, and because of the risk due to maternal epilepsy itself. It should be mentioned that, in contrast with classical antiepileptic drugs, no dysmorphic features have been reported to date. After treatment in the first trimester, termination of pregnancy is not indicated. As is the case with other anticonvulsants, especially with combination therapies, an expanded prenatal diagnosis with a detailed ultrasound testing during the second trimester should be performed to rule out major disturbances of structural development. Because the pharmacokinetic changes display marked inter-patient variation, frequent lamotrigine-level monitoring and appropriate dose adjustments are advised in the period before and during pregnancy and after delivery. Of 21 women who became pregnant on levetiracetam during clinical trials, 2 had babies with abnormalities, but both women were exposed to other anticonvulsants as well. Case reports are available for three pregnancies with exposure to levetiracetam in monotherapy with no adverse outcomes (Long 2003). A report on 11 pregnancies exposed to levetiracetam (Ten Berg 2005) reported no congenital malformations, but 3 of 9 babies had low birth weight (1 pregnancy miscarried and 1 was terminated). The largest case series published so far (Morrow 2006) reported 22 pregnancy outcomes with exposure to levetiracetam monotherapy, and observed no case of congenital malformation. Six (21%) of the newborns were small for date; all of them were exposed to polytherapy. An interaction between levetiracetam and other anticonvulsants was proposed as a mechanism for growth retardation. Among 37 documented pregnancies (Andermann 1994, Friis 1993, Bulau 1988), the following outcomes were observed: 3 spontaneous abortions, 2 infants with mild dysmorphic features that disappeared later in life, 1 infant with spina bifida (mother also received valproate), 1 newborn with "amniotic bands", and 31 normal infants, including a pair of twins. An extensive literature review (Montouris 2005) identified a total of 248 pregnancies involving maternal exposure to oxcarbazepine monotherapy and 61 involving adjunctive therapy. There were four malformations associated with oxcarbazepine adjunctive therapy ­ i. With additional cases documented by Artama (2005), Meischenguiser (2004), Sabers (2004), and Kaaja (2003), more than 300 pregnancies were documented; two-thirds of them were exposed to monotherapy. Available human data do not indicate a substantial teratogenic risk of oxcarbazepine monotherapy. Oxcarbazepine may be continued during pregnancy if effective in controlling seizures. However, as an additional preventive measure, a detailed ultrasound diagnosis should be conducted in the second trimester as well as an -fetoprotein determination in the maternal serum 278 2. To decrease the risk of coagulation disturbances in the fetus and newborn, the newborn should receive 1 mg of vitamin K (preferably intramuscularly) at birth and 1 mg orally every 3 days in the first 2 weeks of life (see also section 2. Clinical trials covering a few women with firsttrimester exposure have not as yet indicated substantial teratogenicity. There were indications for skeletal abnormalities and neural tube defects in some animal experiments. However, as an additional preventive measure, a detailed ultrasound diagnosis should be conducted in the second trimester. In the post-marketing surveillance system of the company, 38 exposed pregnancies (17 of them monotherapy) were registered; 3 of the polytherapy-exposed infants had congenital anomalies. Yerby (2003) mentioned 5 cases of hypospadias among 110 pregnancies reported to the drug company without details. Additional case reports with normal outcomes were reported by Цhman (2002), and Vajda (2003). In summary, about 150 exposed pregnancies so far have a documented outcome, but this experience is insufficient to rule out a moderate risk, given the fact that topiramate is teratogenic in animal experiments, sometimes with an equivalence of only 20% of the human dosage (per surface area). An expanded prenatal diagnosis with a detailed fetal ultrasound during the second trimester should be performed to rule out major disturbances of structural development. Neuropathological effects have been reported in the developing rat brain (Qiao 2000). Transplacental passage of vigabatrin has been demonstrated in animal experiments (Aboulrazzaq 2001). Cases of diaphragmatic hernia (Kramer 1992) and hypospadias (Lindhout 1994) were reported in children also exposed to carbamazepine. Vajda (2003) found no teratogenic effects among 8 pregnancies reported to the Australian Epilepsy Register. Vigabatrin is under discussion because it has been found to cause concentric visual-field defects in 30­40% of the users (Spencer 2003, Kдlviдinen 1999), but there is insufficient information available on visual-field defects in children who have been exposed prenatally (Sorri 2005). There is, to date, insufficient experience with humans to rule out a teratogenic effect of vigabatrin. When vigabatrin treatment occurs in the first trimester, termination of pregnancy is not indicated. As with other anticonvulsants, especially with combination therapy, an increased risk of birth defects must be anticipated. To decrease the risk of coagulation disturbances in the fetus and newborn, the newborn should receive 1 mg of vitamin K (preferably intramuscularly) at birth and 1 mg orally every 3 days in the first 2 weeks of life (see also section 1. There were no birth defects after monotherapy; however, 2 infants among those who had been exposed to combination therapy (valproate and/or phenytoin) had birth defects (1 atrioseptal defect and 1 anencephaly) (Kondo 1996). Two additional cases under anticonvulsant combination therapy were reported, both healthy newborns (Kawada 2002). As is the case with other anticonvulsants, especially with combination therapies, an increased rate of birth defects is to be References 281 expected. Antiepileptic drug use of women with epilepsy and congenital malformations in offspring. Time-course of transplacental passage of diazepam: influence of injection-delivery interval on neonatal drug concentrations. Influence of pregnancy and folic acid on phenytoin metabolism by rat liver microsomes. Pharmacokinetics of oxcarbazepine and 10hydroxy-carbazepine in the newborn child of an oxcarbazepine-treated mother. Pregnancy outcome in infants prenatally exposed to newer anticonvulsants . 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Goldenhar syndrome, anterior encephalocele and aqueductal stenosis following fetal primidone exposure. Increased risk for non-syndromic cleft palate among infants exposed to lamotrigine during pregnancy . Fetal growth, major malformations, and minor anomalies in infants born to women receiving valproic acid. Pattern of malformations in the children of women treated with carbamazepine during pregnancy. Lamotrigine in the treatment of pregnancy patients with Juvenile Myoclonic Epilepsy. Enzyme-inducing antiepileptic drugs in pregnancy and the risk of bleeding in the neonate. A register study of maternal epilepsy and delivery outcome with special reference to drug use. Valproic acid is known to cause hypospadias in man but does not reduce anogenital distance or causes hypospadias in rats. Prenatal diazepam exposure in rats: longlasting functional changes in the offspring. Dysmorphic features: an important clue to the diagnosis and severity of fetal anticonvulsant syndromes. 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