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After menopause discount decadron 1mg on-line skin care educator jobs, female bones show accelerated resorption rates causing the porosity to increase generic decadron 0.5 mg mastercard skin care yogyakarta, hence reducing the quality of bone (Boutroy et al best decadron 0.5 mg skin care network barnet ltd. Species this review has mainly focused on human bone purchase decadron 1 mg with mastercard acne y embarazo, however use of animal tissue is common in testing of mechanical properties of bone. For example, porcine femur is weaker in tension and compression that human bone (Fung, 1993; An, 2000. Chapter 2 | Page 27 this means that care must be taken when transferring and comparing test results between species. Embalming or Fixation Formalin fixation of biological tissue conserves the tissue as it has antimicrobic effects, therefore allowing for long duration tests. When a tissue is formalin-embalmed to preserve the tissue, the collagens are cross-linked, which can alter the mechanical properties of the bone. The change is dependent on the formalin concentration used and the duration of the preservation of the sample (Ohman et al. Storage Method Sometimes the method by which a bone sample is stored may alter its mechanical properties. Linde and Sorensen (1993) studied the effects of freezing and thawing as well as storage by freezing and in ethanol on compressive properties of cancellous bone. They found that freezing and thawing up to five times did not alter the stiffness of the bone, however the viscoelastic properties showed small, but significant changes after 100 days of storage by both freezing and in ethanol. They found that freezing of bone samples to -20°C, 70°C, and -196°C for 2 weeks did not have significant effects on the strength of those bones, however freeze drying samples did result in a significant reduction in torsional strength of the long bones. They did not find any significant differences between the mechanical properties of the three tests groups, implying that freezing and storage for up to 7 months do not significantly alter the mechanical properties of the bone. Chapter 2 | Page 28 It can be seen from the literature that freezing is the best method of storage of bone samples, as it does not significantly alter their mechanical properties. Many studies have been performed to understand the effects of various in vitro techniques on the mechanical properties of bone, with the main purpose of these studies being prevention of any alteration in mechanical properties of bone tested in vitro. They also reported only very slight reduction in ultimate tensile strength, maximum strain and modulus of elasticity, as well as no significant change in hardness. They found that after 8 weeks in embalming solution, the specimens had significantly lower Youngs modulus (24%) and higher yield strains (20%) and ultimate strains (53%) than the control groups. No significant differences were reported in yield stress, ultimate stress and hardness. This difference may be explained by the difference in the species tested (bovine versus human), as well as the different specimen geometries. Both studies however confirm that the Chapter 2 | Page 29 mechanical properties of the bone may change significantly following embalming. They found that the results in bending and tension loading were almost unaffected by fixation of specimens in formaldehyde, however the impact strength was decreased significantly after fixation of the specimens. Studies have been performed where effects of boiling and autoclaving on mechanical properties of bone have been studied. They also found that compressive modulus of trabecular bone whilst unaffected by boiling can be reduced by 58% following autoclaving at 127°C for 10 minutes. They heated cartilage to temperatures lower, at and beyond the denaturing temperature of collagen, and found that heating the bone specimens to +160°C denatures cartilage significantly and also changes the ultimate strength and work to fracture of the bone. They reported no significant changes in the elastic modulus of bone even when heated up to 180°C. They concluded that the toughness and strength of bone relates significantly to the integrity of collagen structure, and the stiffness of the bone is affected by the mineral phase of the bone rather than the collagen content. Chapter 2 | Page 30 the findings above have been confirmed by further studies: Viceconti et al. Research has shown that cycles of freezing and thawing as well as freezing for long periods of time does not have any significant effects on the mechanical properties of bone, however freeze-drying the tissue can significantly reduce the bone strength. The effects of this process on mechanical properties of bone have been studied, and it has been found that high doses of gamma irradiation can alter the mechanical properties of bone significantly. They found that gamma irradiation (Co60) with a dose of 10kGy did not affect the compressive modulus, yield point, energy absorption and maximum stress of these specimens; however a dose of 25kGy reduced those properties by 61% to 69%. Various other studies have found similar results to the Knaepler study (Fideler et al. It is known that gamma irradiation causes direct molecular chain scission as well as promoting cross-linking between molecular chains in collagenous materials. The mobility of the molecules present in the material affects the Chapter 2 | Page 31 cross-linking process, and the radiation dose controls the chain scission. Tissues are usually irradiated while suspended in water, or frozen in presence of water. This reduces the mechanical influence of gamma radiation on the tissue, hence to obtain higher changes in mechanical properties of bone, the tissues must be irradiated without the presence of liquids or after freeze-drying (Smith and Kearney, 1996. They tested canine femurs in four-point cyclic bending under load control until they had lost between 5-43% of their original stiffness. They detected the presence of micro-damage by staining the loaded sections of the bone with basic fuchsin. They found that significant micro-damage occurred after the bone had lost 15% of its elastic modulus (Figure 2-20), and a quadratic ratio defined the crack density and stiffness loss relationship. Figure 2-20 – Stiffness loss in each canine specimen group (%) versus frequency of microcracks seen in the tissue (%) in each group following application of four-point cyclic loading. He found that this process had no significant effect on bending Youngs modulus of bone; however the bending strength was reduced by 5%.

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Morphological classification of circu latory disorders of the canine and feline liver cheap 1 mg decadron mastercard acne around nose. Regenerative and fibrotic pathways in canine hepatic portosystemic shunt and portal vein hypoplasia buy cheap decadron 1 mg online acne extractor, new models for clinical hepatocyte growth factor treatment purchase 0.5mg decadron with amex acne on chest. Acquired portosystemic shunting in 2 cats secondary to congenital hepatic fibrosis order 1mg decadron fast delivery acne nodule. Portal hypertension associated with primary hypo plasia of the hepatic portal vein in dogs. Characterization of hepatoportal microvascular dysplasia in a kindred of cairn terriers. Ultrasonographic identification and characterization of congenital portosystemic shunts and portal hypertensive disorders in dogs and cats. Characterisation of 11 beta-hydroxyste roid dehydrogenases in feline kidney and liver. Impaired 11 beta-hydroxysteroid dehydrogenase contributes to renal sodium avidity in cirrhosis: hypothesis or fact Effect of chenodeoxycholic acid on 11beta-hydroxysteroid dehydrogenase in various target tissues. Chenodeoxycholic acid and deoxycholic acid inhibit 11 beta-hydroxysteroid dehydrogenase type 2 and cause cortisol induced transcriptional activation of the mineralocorticoid receptor. Reduced activity of 11beta-hydroxyste roid dehydrogenase in patients with cholestasis. Inhibition of 11beta-hydroxysteroid dehy drogenase by bile acids in rats with cirrhosis. Diagnostic value of fasting plasma ammonia and bile acid concentrations in identification of portosystemic shunting in dogs. Rectal ammonia tolerance test in the evaluation of portal circulation in dogs with liver disease. Changes in cerebral receptors for gamma aminobutyric acid in patients with hepatic encephalopathy. Effects of a branched-chain amino acid-enriched diet on chronic hepatic encephalopathy in dogs. Chronic glucocorticoid excess and impaired osmoregulation of vasopressin release in dogs with hepatic encephalopathy. Arterial and venous ammonia concentrations in the diagnosis of canine hepato-encephalopathy. Evaluation of ammonia measurements in dogs with two analysers for use in veterinary practice. Correlation between coagulation profile find ings and bleeding complications after ultrasound-guided biopsies: 434 cases (1993–1996. Complications after ultrasound-guided biopsy of abdominal structures in dogs and cats: 246 cases (1984–1991. Plasma coagulation factor abnormalities in dogs with naturally occurring hepatic disease. Alterations of prothrombin time and activated partial thromboplastin time in dogs with hepatic disease. Severe cholestasis leads to vitamin D depletion without perturbing its C-25 hydroxylation in the dog. Use of a test for proteins induced by vitamin K absence or antagonism in diagnosis or anticoagulant poisoning in dogs. Controlling acute varicealhem orrhage Safe vasoactive drugs are started as soon as possible, prior to diagnostic endoscopy. H ypercoagulability can occur in patients w ith liver disease, especially those w ith cholestatic disease. H epatorenalsyndrom e • Pre renal acute kidney injury that occurs in decom pensated cirrhosis. Spontaneous bacterial peritonitis • Consists of fever, leukocytosis, abdom inal pain, and decreased bow el sounds • ^ gut w all perm eability >grow th of bacteria in peritoneal fluid • A ssociated vm acrophage func on • Risk factors low protein in ascitic fluid, variceal bleeding • A ntibiotic prophylaxis in Pts w ith G I haem orrhage is recom m ended. O ther agents m etroinidazole or neom ycin • Flum azenilis effective in about 30% of patients w ith severe hepatic encephalopathy, but the drug is short acting requiring iv adm inistration. Sedative and Respiratory depressant effects – A dm inistration interval should be increased 1. Postoperative pain relief • Thoracic epidural analgesia provides excellent analgesia for liver resections but restricted due to coagulation defects • the catheter is usually inserted at the T6 T9 space. Ropivacaine or bupivacaine are com m on local anesthetics used w ith or w ithout the addition of sm all am ounts of opioids such as fentanyl,sufentanil, hydrom orphone or m orphine. N A C, in addition to its direct antioxidant property, replenishes glutathione and acts as a free radical scavenger. M A M A, or M axim um A m plitude, direct function of the m axim um Platelets dynam ic properties of fibrin and platelet bonding and represents the ultim ate strength of fibrin clot. They are usually found in large and medium sized breeds of dogs, such as Irish wolfhounds, Labrador retrievers, old English sheepdogs, and Australian shepherds. They have also been reported in some cats and in small breeds, particularly miniature poodles. Single congenital extrahepatic portosystemic shunts connect the portal vein or one of its tributaries to the caudal vena cava or the azygos vein. They are usually found in small breed dogs, such as pugs, schnauzers, Maltese, Shih tzus, and especially Yorkshire terriers, and are the most common type of congenital shunt in cats. Extrahepatic multiple acquired portosystemic shunts connect the portal tributaries to the caudal vena cava, usually near the renal veins. They occur as a result of end stage liver disease (cirrhosis) and portal hypertension.

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Figure 1 illustrates how the clinical importance of effect estimates were considered along with imprecision cheap decadron 1mg online the skincare shop, and the usual way of documenting this is in the evidence statements throughout this guideline purchase decadron 1mg with amex acne light mask. Results are imprecise when studies include relatively few patients and few events and thus have wide confidence intervals around the estimate of the effect relative to the clinically important threshold order 1mg decadron acne on arms. In the absence of any full economic evaluations cheap decadron 1mg without prescription skin care 1 month before marriage, studies that reported cost per hospital, or reported average cost-effectiveness without disaggregated costs and effects, were considered for inclusion on a case by case basis. Remaining studies were prioritised for inclusion based on their relative applicability to the development of this guideline and the study limitations. For more details about the assessment of applicability and methodological quality see the economic evaluation checklist (The Guidelines Manual. The economic evidence profile shows, for each economic study, an assessment of applicability and methodological quality, with footnotes indicating the reasons for the assessment. These assessments were made by the health economist using the economic evaluation checklist from the Guidelines Manual182. Limitations An assessment of methodological quality of the study(a): Minor limitations – the study meets all quality criteria, or the study fails to meet one or more quality criteria, but this is unlikely to change the conclusions about cost effectiveness. Studies with very serious limitations would usually be excluded from the economic profile table. Other comments Particular issues that should be considered when interpreting the study. Incremental cost the mean cost associated with one strategy minus the mean cost of a comparator strategy. See Appendix J for details of the health economic analysis/analyses undertaken for the guideline. Expert advisors were invited to provide advice on how to interpret the identified evidence. The considerations for making consensus based recommendations include the balance between potential harms and benefits, economic or implications compared to the benefits, current practices, recommendations made in other relevant guidelines, patient preferences and equality issues. The main considerations specific to each recommendation are outlined in the Evidence to Recommendation Sections preceding the recommendation section in each chapter. The recommendations cited here are a guide and may not be appropriate for use in all situations. The decision to adopt any of the recommendations cited here must be made by the practitioners in light of individual patient circumstances, the wishes of the patient, clinical expertise and resources. For each set of guidelines, an electronic search was conducted for current national and international guidelines. The emphasis given to each guideline depended on the rigour of its development and its comprehensiveness in relation to the review questions. Review questions for the systematic reviews of the literature were developed for each set of guidelines following advice from key stakeholders and expert advisors. No research designs were specifically excluded but wherever possible, in use rather than in vitro studies were retrieved. The second sift involved a critical review of the full text, and articles relevant to a review question were critically appraised. At this stage, expert advice derived from seminal works and appraised national and international guidelines were considered. Although economic opinion was considered for each review question, the economic scope described above did not identify any high quality cost-effectiveness evidence,. These results were then subjected to sensitivity analysis where key parameter values were varied. Areas were targeted where the impact on resource use was likely to be substantial. In addition, where there was no evidence of difference in clinical outcomes between interventions, simple cost analyses were performed to identify the potential resource consequences. Factors influencing the guideline recommendations included: the nature of the evidence; the applicability of the evidence; costs and knowledge of healthcare systems. The criteria used for selecting these recommendations are listed in detail in the Guidelines Manual182. For each key recommendation listed, the selection criteria and implementation support points are indicated by the use of the letters shown in brackets below. They considered whether a recommendation: Requires changes in service delivery (W) Requires retraining of professionals or the development of new skills and competencies (X) Affects and needs to be implemented across various agencies or settings (complex interactions) (Y) May be viewed as potentially contentious, or difficult to implement for other reasons (Z) 4. Wherever care is delivered, healthcare workers musta have available appropriate supplies of: materials for hand decontamination sharps containers personal protective equipment. Educate patients and carers about: the benefits of effective hand decontamination the correct techniques and timing of hand decontamination when it is appropriate to use liquid soap and water or handrub the availability of hand decontamination facilities their role in maintaining standards of healthcare workers hand decontamination. Hands must be decontaminated in all of the following circumstances: immediately before every episode of direct patient contact or care, including aseptic procedures immediately after every episode of direct patient contact or care immediately after any exposure to body fluids immediately after any other activity or contact with a patients surroundings that could potentially result in hands becoming contaminated immediately after removal of gloves. All catheterisations carried out by healthcare workers should be aseptic procedures. After training, healthcare workers should be assessed for their competence to carry out these types of procedures. When changing catheters in patients with a long-term indwelling urinary catheter: do not offer antibiotic prophylaxis routinely consider antibiotic prophylaxisb for patients who: – have a history of symptomatic urinary tract infection after catheter change or – experience traumac during catheterisation. Before discharge from hospital, patients and their carers should be taught any techniques they may need to use to prevent infection and safely manage a vascular access deviced. Healthcare workers caring for a patient with a vascular access deviced should be trained, and assessed as competent, in using and consistently adhering to the infection prevention practices described in this guideline. Decontaminate the skin at the insertion site with chlorhexidine gluconatee in 70% alcohol before inserting a peripheral vascular access device or a peripherally inserted central catheter.

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Please refer to the hand decontamination chapter for a detailed explanation of products to use for hand decontamination purchase decadron 1mg with amex skin care coconut oil. This recommendation is consistent with the when to wash your hands recommendation (see section 6 discount 1 mg decadron mastercard acne solutions. A recommendation from the earlier 2003 guideline was removed following this update: “Following hand antisepsis order decadron 1 mg with visa acne los angeles, clean gloves and a no-touch technique or sterile gloves should be used when changing the insertion site dressing discount 0.5mg decadron with mastercard acne vulgaris causes. An aseptic techniquess must be used for vascular access device Recommendations catheter site care and when accessing the system. Trade off between clinical None of the outcomes identified as important were reported in the literature. The term vascular access device has been inserted to avoid confusion as urinary catheters are also discussed in the guideline. This addition ensures that this recommendation can be read as a standalone recommendation. See also recommendations regarding asepsis discussed in the Long term urinary catheters and Enteral feeding chapters. The following review question was prioritised for update to determine the most effective decontamination solution for skin decontamination prior to insertion of peripheral vascular access devices, as it was felt there are more types of decontamination products are available since 2003. For examples, in some comparisons, the type and concentration of alcohol used is specified whereas others just noted “alcohol. Only the P values were reported in for some outcomes and 95% confidence intervals were not available. One cost-effectiveness analysis by Chaiyakunapruk and colleagues (2003)40 was identified in this update. Table 83: Skin decontamination product costs Decontamination product Total product cost Unit cost 7% Povidone Iodine in aqueous solution 2. In some cases a line Tariff,186 expert change may be necessary, which opinion would incur a hospital visit and possible inpatient admission. Table 85: Vascular catheter infection-related quality of life estimates Health state Utility estimate Note Source Full health 0. There was no statistically significant difference in the number of catheter tip colonisation between 0. Decontaminate the skin at the insertion site with chlorhexidine gluconatett in 70% alcohol before inserting a peripheral vascular access device or a peripherally inserted Recommendations central catheter. Trade off between clinical Reducing the risk of infections was considered the priority, balanced against benefits and harms the very small risk of chlorhexidine hypersensitivity. Compared to alcohol on its own or povidone iodine applied before or after 70% alcohol, the percentage of patients with phlebitis seemed to be lower for patients who used 0. Compared to alcohol on its own, there were significantly fewer catheter tip colonisations for 2% chlorhexidine gluconate in alcohol. In addition, data were collected from hospitalised patients, and may not be applicable to the community setting. Although the level of uncertainty in the evidence found is high and it is difficult to conclude that one particular antiseptic solution is better than another, the trend in the evidence suggests that chlorhexidine gluconate in alcohol may be more effective than alcoholic povidone iodine solutions. Other considerations In the absence of direct comparisons between different concentrations of chlorhexidine in alcohol it is unclear which is the optimal concentration for the best balance of efficacy against potential risk of chlorhexidine hypersensitivity. They also noted that the reduction of microorganisms and residual effect is greater at higher concentrations of chlorhexidine gluconate. The correct technique and volume of decontamination solution was considered critical to achieve skin decontamination, see section 6. Iodine preparation for the purpose of disinfection is usually in the form of aqueous solution. Therefore, iodine was considered as not practical in the community because it takes a longer time to dry than chlorhexidine, has residual staining and there are risks associated with iodine absorbed through the skin. They noted that this could reduce the chance of confusion of which to solution to use. The following question aims to determine which types of dressing for peripherally or centrally inserted vascular access device sites is the most effective at preventing healthcare-associated infections. Craven 198550 randomised catheter sites rather than patients, therefore patients were included in the study up to 8 times. Maki 1987154 randomised catheter sites rather than patients, therefore patients were included in the study more than once. This topic was originally identified as a high-priority area for original economic modelling. However, after reviewing the clinical evidence it was decided that there was insufficient comparative clinical evidence to inform a cost-effectiveness model. One study was a cost analysis by Crawford et al (2004)51,51 comparing chlorhexidine dressings to standard dressings in patients with central venous catheters. No studies from the previous 2003 guideline met the inclusion criteria for this review question. Use a sterile transparent semipermeable membrane dressing Recommendations to cover the vascular access device insertion site. They were downgraded due to: limitations in study design; indirectness as no community data was identified; and imprecision due to wide confidence intervals and low event numbers. No clinical evidence was identified for silver or chlorhexidine-impregnated dressings. Other considerations Dressing adherence and water resistance were considered important issues in community settings as patients place a high value on being able to conduct their daily tasks, such as showering and washing. Consider a sterile gauze dressing covered with a sterile transparent semipermeable membrane dressing only if the patient has profuse perspiration, or if the vascular access device insertion site is bleeding or oozing.

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Poorly controlled pre 220 Guidelines for Perinatal Care gestational diabetes mellitus leads to serious end-organ damage that may eventually become life threatening discount decadron 0.5 mg with visa scin care. In turn generic 1mg decadron overnight delivery skin care news, pre-existing diabetes-related end organ disease may have deleterious effects on obstetric outcomes generic 0.5 mg decadron with visa acne hyperpigmentation treatment. The rates of spontaneous preterm labor buy decadron 1 mg otc acne medicine, preeclampsia, intrauterine growth restriction, and primary cesarean delivery are all increased in women with pregestational diabetes mellitus. Fetal and Neonatal Complications the risk of congenital abnormalities is increased in women with pre-existing diabetes. The fetus of a woman with poorly controlled diabetes is at increased risk of intrauterine fetal death and is more likely to weigh more than 4,000 g with a disproportionate concentration of fat around the shoulders and chest, which more than doubles the risk of shoulder dystocia at vaginal delivery. The neonatal consequences of poorly controlled pregestational diabetes mellitus during pregnancy include profound hypoglycemia, a higher rate of respiratory distress syndrome, polycythemia, organomegaly, electrolyte disturbances, and hyperbilirubinemia. Long-term outcomes for neonates with type 1 diabetes mellitus include obesity and carbohydrate intolerance. Fetal Assessment An ultrasound examination early in gestation can be used not only to dem onstrate fetal viability but also to accurately date the pregnancy. Most major anomalies can be detected at 18–20 weeks of gestation by a specialized (or targeted) ultrasound examination that includes a carefully performed assess ment of fetal cardiac structure, including the great vessels. Antepartum fetal monitoring is a valuable approach and can be used to monitor the preg nancies of women with pregestational diabetes mellitus (see also “Antepartum Tests of Fetal Well-Being in Chapter 5. Antepartum Management the management of diabetes in pregnancy must focus on excellent glucose con trol achieved using a careful combination of diet, exercise, and insulin therapy. Patients may need to be seen every 1–2 weeks during the first two trimesters and weekly after 28–30 weeks of gestation. A registered dietitian may be of value in providing an individualized nutrition program. Pregnancy is characterized by increased insulin resistance and reduced sen sitivity to insulin action. Insulin requirements will increase throughout preg Obstetric and Medical Complications 221 nancy, most markedly in the period between 28–32 weeks of gestation. Most insulin used in the treatment of pregestational diabetes mellitus is biosynthetic human insulin. Short-acting or rapid-acting insulins are administered before meals to reduce glucose elevations associated with eating. Longer acting insu lins are used to restrain hepatic glucose production between meals and in the fasting state. Intermediate-acting insulin usually is given before breakfast with a rapid-acting or short-acting insulin and before the evening meal or at bedtime. Frequent self-monitoring of blood glucose is essential to achieve euglycemia without significant hypoglycemia during pregnancy. Even with meticulous monitoring, hypoglycemia is more frequent in pregnancy than at other times, particularly in patients with type 1 pregestational diabetes mellitus. Patients and their families should be taught how to respond quickly and appropriately to hypoglycemia. Intrapartum Management Optimal timing of delivery relies on balancing the risk of intrauterine fetal death with the risks of preterm birth. Early delivery may be indicated in some patients with vasculopathy, nephropathy, poor glucose control, or a prior stillbirth. If corticosteroids are administered to accelerate lung maturation, an increased insulin requirement over the next 5 days should be anticipated, and the patients glucose levels should be closely monitored. In contrast, patients with well-controlled diabetes may be allowed to progress to their expected date of delivery as long as antenatal testing remains reassuring. Expectant manage ment beyond the estimated due date generally is not recommended. To prevent traumatic birth injury, cesarean delivery may be considered if the estimated fetal weight is greater than 4,500 g in women with diabetes. Induction of labor in pregnancies with a fetus with suspected macrosomia has not been found to reduce birth trauma and may increase the cesarean delivery rate. During induction of labor, maternal glycemia can be controlled with an intravenous infusion of regular insulin titrated to maintain hourly readings of blood glucose levels less than 110 mg/dL. Avoiding intrapartum maternal hyperglycemia may prevent fetal hyperglycemia and reduce the likelihood of subsequent neonatal hypoglycemia. Patients who are using an insulin pump may continue their basal infu sion during labor. One half of the pre delivery dose may be reinstituted after starting regular food intake. Breastfeed ing should be encouraged in women with pregestational diabetes mellitus. Thyroid Disease Because thyroid disease is the second most common endocrine disease that affects women of reproductive age, obstetricians often care for patients in whom alterations in thyroid gland function have been previously diagnosed. In addi tion, both hyperthyroidism and hypothyroidism may initially manifest during pregnancy. During pregnancy, the diagnosis of thyroid abnormalities is con fused by significant but reversible changes in maternal thyroid physiology that lead to alterations in thyroid function tests during gestation. However, there are gestational age-specific nomograms and thresholds for evaluating thyroid status during pregnancy. The presence of maternal thyroid disease is important information for the pediatrician to have at the time of delivery. Thyroid Function Testing Thyroid testing in pregnancy should be performed on symptomatic women and women with a personal history of thyroid disease or other medical conditions associated with thyroid disease (eg, type 1 diabetes mellitus. The performance of thyroid function tests in asymptomatic pregnant women who have a mildly enlarged thyroid is not warranted.

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