NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion
NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion
Module III: Men’s and Women’s Health Discussion
Must post first.
Subscribe
Consider the following scenarios:
LW is a 32 year old female patient who comes to your medical clinic for primary care. She has been on hormonal contraceptives for years, although she’s just been married and has stopped her pills in hopes of becoming pregnant. Her PMHx includes obesity, HTN (diagnosed 3 years ago), familial hypercholesterolemia, and PCOS. Her current medications are as follows: Metformin 2000 mg PO daily, Lisinopril 10 mg PO daily, rosuvastatin 5 mg PO daily, and a multivitamin.
GD is an 82-year-old patient is taking 2 mg of terazosin for BPH every morning. He comes in complaining of dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS).
How should you advise these patients and manage their medications? What was the process you went through to assess the current medications and to recommend an updated regimen?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
Most Recent Activity Least Recent Activity Newest Thread Oldest Thread Author First Name A-Z Author First Name Z-A Author Last Name A-Z Author Last Name Z-A Subject A-Z Subject Z-A
Men and Women’s Health Discussion
Subscribe
Anna McMullen posted Sep 14, 2020 10:38 AM
Upon evaluating LW, I would assess the safety and necessity of her prescribed medications in relation to her medical history and her goals. LW wishes to get pregnant, therefore any medications that she is taking should be safe for pregnancy. LW also has HTN, and is taking Lisinopril 5mg po QD, so it is necessary for a medication to address her HTN be prescribed which is also safe for pregnancy. Currently, LW is taking metformin 200mg po QD, most likely for her PCOS since it is not indicated that she is T2DM; the necessity of this medication must be evaluated. She is also taking rosuvastatin 5mg po QD for familial hypercholesteremia, so the safety of this medication must be evaluated. ACE inhibitors and ARBs are not considered safe during pregnancy, therefore lisinopril 5mg should be discontinued while LW is trying to conceive (Khalil et al., 2016). Women with pre-existing HTN should be carefully monitored throughout pregnancy and should have their BP stabilized before conception due to increased risk of preeclampsia; 22-25% of women with chronic HTN will develop preeclampsia during pregnancy (Khalil et al., 2016). Acceptable medications for the treatment of HTN during pregnancy are the beta-blocker labetalol and the alpha-2 agonist, methyldopa; however, labetalol is not considered safe to use during breast feeding, so if this is something LW plans to do, she may want to consider methyldopa as a first-line option (Khalil et al., 2016).LW should continue her multivitamin, ensuring that it has an adequate amount of folic acid, or consider switching to a prenatal multivitamin. Liu et al. (2018) found that women who supplemented with multivitamins with folic acid significantly reduced their risk of preeclampsia and gestational diabetes, both conditions that LW is at risk for developing during pregnancy.ReferencesBortnick, E., Brown, C., Simma-Chiang, V., & Kaplan, S. A. (2020). Modern best practice in the management of benign prostatic hyperplasia in the elderly. Therapeutic Advances in Urology, 12, 175628722092948. https://doi.org/10.1177/1756287220929486Herschorn, S., Staskin, D., Schermer, C. R., Kristy, R. M., & Wagg, A. (2020). Safety and tolerability results from the pillar study: A phase iv, double-blind, randomized, placebo-controlled study of mirabegron in patients ≥ 65 years with overactive bladder-wet. Drugs & Aging, 37(9), 665–676. https://doi.org/10.1007/s40266-020-00783-wLiu, C., Liu, C., Wang, Q., & Zhang, Z. (2018). Supplementation of folic acid in pregnancy and the risk of preeclampsia and gestational hypertension: A meta-analysis. Archives of Gynecology and Obstetrics, 298(4), 697–704. https://doi.org/10.1007/s00404-018-4823-4Terazosin (oral route) side effects – mayo clinic. (2020, August 1) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion . Mayo Clinic. https://www.mayoclinic.org/drugs-supplements/terazosin-oral-route/side-effects/drg-20066315?p=1
Lundberg, G., & Mehta, L. (2018, May 14). Familial hypercholesterolemia and pregnancy – American college of cardiology. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2018/05/10/13/51/familial-hypercholesterolemia-and-pregnancy
Khalil, A., O’Brien, P., & Townsend, R. (2016). Current best practice in the management of hypertensive disorders in pregnancy. Integrated Blood Pressure Control, Volume 9, 79–94. https://doi.org/10.2147/ibpc.s77344
Haas, J., & Bentov, Y. (2017). Should metformin be included in fertility treatment of pcos patients? Medical Hypotheses, 100, 54–58. https://doi.org/10.1016/j.mehy.2017.01.012
Astellas Pharma US, Inc. (2018). MYRBETRIQ (mirabegron extended-release tablets) for oral use [Prescribing Information (PI)]. astellas.us. https://astellas.us/docs/Myrbetriq_WPI.pdf
GD is currently taking terazosin 2mg po QD for BPH, although it is also commonly prescribed for HTN, and is experiencing one of the most common side effects, dizziness, as well as muscle weakness and LUTS (Terazosin (Oral Route) Side Effects – Mayo Clinic, 2020). Due to GD’s age, the most commonly prescribed medications for BPH may not be appropriate. Alpha blockers pose an increased risk for the elderly patient, as they may also cause dizziness, orthostatic hypotension, and may lead to falls and subsequent injuries (Bortnick et al., 2020). Though 5-alpha reductase inhibitors (5-ARIs) may also commonly be considered, Bortnick et al. (2020), discussed that there is a significant risk of depression, self-harm, and suicide in elderly adults following administration. Phosphodiesterase inhibitors (PDE5I) are now approved for males with BPH and ED, however, men over the age of 75 have shown increased risk of dizziness and diarrhea and there is no mention of GD experiencing ED (Bortnick et al., 2020). Anticholinergics are another class of medications that address LUTS, however, their side-effect profile also poses increased risk for the elderly patient, including increased risk of CNS side-effects including confusion and dizziness, and should therefore be avoided (Bortnick et al., 2020). Mirabegron, the only beta-3 adrenergic agonist available, is an appropriate medication that should be considered for GD, as it will address the LUTS he is experiencing, and lacks the negative side-effects of anticholinergic alternatives (Haas & Bentov, 2017). The PILLAR study (Herschorn et al., 2020) evaluated the safety and efficacy of mirabegron in adults with overactive bladder (OAB) aged 65 years and older and found that side-effect profile in this population was comparable to placebo. Although mirabegron is not currently indicated for BPH, its safety has been evaluated in a urodynamic study with men with bladder outlet obstruction (BOO) and LUTS; it was found that mean maximum flow rate and mean detrusor pressure were not affected (Astellas Pharma US, Inc., 2018). Mirabegron provides an alternative for elderly patients, such a GD, that are trying to minimize LUTS while also minimizing side-effect profile.
Total cholesterol in the general population while pregnant can increase 25-50% and LDL can increase up to 66%, therefore, women with familial hypercholesterolemia, such as LW, may see even greater increases while pregnant making management important (Lundberg & Mehta, 2018). Statin therapy, such as the rosuvastatin that LW is prescribed, is contraindicated during pregnancy, as well as non-statin alternatives such as ezetimibe, niacin, and fibrates that have been shown to increase teratogenicity (Haas & Bentov, 2017). Bile acid sequestrants, such as cholestyramine, colestipol, and colesevelam, are currently the only class of medications currently acceptable during pregnancy since they are not absorbed systemically and therefore pose no fetal risk (Lundberg & Mehta, 2018) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
According to Haas & Bentov (2017) metformin has historically been prescribed for patients with PCOS for the whole duration of pregnancy, reportedly lowering pregnancy loss, reducing gestational DM, and not increasing birth defects. However, Hass & Bentov (2017) also found that there has been increased concern over the use of metformin during pregnancy and in their research found that there is no clear advantage in the use of metformin in fertility treatment for PCOS patients and that its use during pregnancy may have long-term consequences on offspring. Therefore, I would recommend that LW discontinue the use of metformin.
Addition to Discussion this week
Subscribe
Kelly Miskovsky posted Sep 18, 2020 9:11 AM
Hi class,GD returns to your clinic after several months of taking tamsulosin, presenting with prostate enlargement and a PSA of 5 ng/mL. What changes would you make to his medications and why?LW was able to successfully get pregnant and now returns to your clinic for her postpartum checkup. She states that she wants to go back on her birth control pills. She mentions she just started taking Augmentin for a sinus infection. What recommendations would you make?
Last post Sep 20, 2020 11:34 PM by Tomiko Edmonds
GD has now been switched to finasteride, which has been effective in treating his BPH for the last several months. He now comes to your clinic also complaining of erectile dysfunction. What changes would you make to his medications?
Some additional scenarios to consider for this weeks module.
Women’s and Men’s Health DiscussionSubscribe
Kathryn Mosholder posted Sep 16, 2020 9:46 PM
Contains unread posts
32 yr old Female with obesity, HTN, family hypercholesterolemia, and PCOs. 82 yr old Male with BPH Case StudyAt this point, our patient is most likely experiencing dizziness and generalized muscle weakness as side effects from taking terazosin since both these are common side effects. His persistent lower urinary tract symptoms are probably a combination of many factors, such as possible infection and dehydration(Chisholm-Burns, 2019). I would assess patient do vital signs, draw labs and take a urine sample to check for infection and other conditions that might be contributing to his signs and symptoms. My recommendation would be to switch him to a reductase inhibitor and an adrenergic antagonist; however, we would need to know his prostate size do to the fact that he might need a TURP as well (Chisholm-Burns, 2019).Chisholm-Burns, M.,Schwinghammer, T., Malone, P., Kolesar, J., Bookstaver, P., & Lee,Dimitropoulos, K., & Gravas, S. (2016). New therapeutic strategies for the treatment of maleOfori, B., Rey, E., & Bérard, A. (2007). Risk of congenital anomalies in pregnant users of statin Podymow, T., & August, P. (2008). Update on the Use of Antihypertensive Drugs inSilva, J., Silva, C. M., & Cruz, F. (2014). Current medical treatment of lower urinary tract more1 UnreadUnread12 ViewsViews
12
1
1 RepliesReplies
1
View profile card for Pawn Johnson-Hunter
Last post Sep 20, 2020 11:33 PM by Pawn Johnson-Hunter
symptoms/BPH: do we have a standard?. Current opinion in urology, 24(1), 21–28. https://doi.org/10.1097/MOU.0000000000000007
Pregnancy. Hypertension, 51(4), 960-969. https://doi.org/10.1161/hypertensionaha.106.075895
drugs. British journal of clinical pharmacology, 64(4), 496–509. https://doi.org/10.1111/j.1365-2125.2007.02905.x
lower urinary tract symptoms. Research and reports in urology, 8, 51–59. https://doi.org/10.2147/RRU.S63446
K. Pharmacotherapy principles & practice (pp. 807-819).McGraw Hill Education.
References
Unfortunately for men, “BPH is the most common benign neoplasm in men who are at least 40 yrs of age,” Pharmacology text. Benign prostatic obstructions help slow all flow through the urinary tract system by blocking the bladder neck, therefore causing LUTS. “Two-thirds of males reported at least one LUTS complaint during their lifetime. They are directly related to the aging process, and influence patients’ lives to various degrees” (Dimitropoulos & Gravas, 2016, para. 1). research is ongoing Silva, Silva & Cruz (2014) suggest “a combination of PDE5i with alpha-blockers provides better symptomatic control than alpha-blockers alone.” PDE5’s assist with side effects of alpha-blockers such as erectile dysfunction, low sex drive, and retrograde ejaculation, an example being Sildenafil while alpha-blockers assist with BPH symptoms such as urinary hesitancy, nocturia, and urinary frequency an example being Tamsulosin. According to Chisholm-Burns, Schwinghammer, Malone, Kolesar, & Bookstaver (2019),s all patients should be treated individually per their signs and symptoms and severity of BPH. Patients with mild BPH need comparative assessment but no medication regiment in this stage (Chisholm-Burns, 2019). Patients with moderate to severe BPH should be treated with Tadalafil or Tadalafil and an adrenergic antagonist if the prostate is less than 30g (Chisholm-Burns, 2019). If the prostate is more significant than 30 g, treat a with reductase inhibitor or a reductase inhibitor and adrenergic antagonist (Chisholm-Burns, 2019).
This patient would like to get pregnant and is taking metformin 2000mg PO daily, Lisinopril 10mg PO daily, Rosuvastatin 5mg PO daily, and a multivitamin. This patient has several comorbidities, and she would like to get pregnant. Metformin 2000mg is ok to take during pregnancy, and she can remain on the multivitamin. Metformin has a side effect of weight loss, so it is essential to monitor the patient for too much weight loss when pregnant. The concerns are Lisinopril and Rosuvasatatin since both are contraindicated during pregnancy. According to Podymow & August (2008), “Labetalol, a nonselective β-blocker with vascular α1-receptor blocking capabilities, has gained wide acceptance in pregnancy.” Another medication that has gained acceptance is Methyldopa and to use labetalol as a second-line agent. Taking Rosuvastatin during pregnancy can be dangerous because cholesterol is essential to fetal development and statins inhibit cholesterol production, it is hazardous to take statins during pregnancy (Ofori, Rey, Berard, 2007) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
Pharmacology Discussion 3
Subscribe
Dianne Cohen posted Sep 17, 2020 6:51 PM
32-year-old female patientFirst, her daily multivitamin should be replaced with prenatal vitamins that also supply the necessary amounts of folic acid to prevent neural tube defects in the baby (Moore et al., 2020). Next, I would address the Lisinopril which is an angiotensin enzyme converting inhibitor (ACE inhibitor). Magee and von Dadelszon write that due to its toxic renal effects during pregnancy, a safer alternative such as methyldopa with a proven research-based safety record warrants its use(2018). In conclusion, the medical management of women attempting to become pregnant is often complicated by an extensive medical history. Whenever possible, it is best to use evidenced-based research when prescribing medications and consult with the obstetrician in order to provide the best possible care for mother and baby.References I would begin my evaluation of my male patient with a complete medical history including all current prescription and non-prescription medications. For example, an over the counter diuretic may increase urgency, and antihistamines commonly found in allergy medicines can lead to urinary retention thus both mimicking lower urinary tract symptoms (LUTS) (Alcarez et al., 2016). Appropriate labs based on patient history include a urinalysis and culture to rule out an infection that also causes LUTS. According to Carbone et al., blood work should include the prostate-specific antigen (PSA) especially if the patient refused a DRE which can also identify an enlarged prostate and other underlying conditions (2016). In conclusion, selecting a medication to treat BPH requires careful consideration and periodic reevaluation especially in the elderly population. Initially, Terazosin probably was an appropriate choice but due to the patients advanced age and presenting symptoms it requires a vigorous and thorough reevaluationReferences https://docs.google.com/document/d/1hVA1-Kcbb-g-sCVdViw0Izuyy3e8DVsJ_7BqvMFMUeU/edit?usp=sharing
Woodard, T., Manigault, K., McBurrows, N., Wray, T., Woodard, L., (2016). Management of Benign Prostatic Hyperplasia in Older Adults. The Consultant Pharmacist, 31(8).
Yuan, J. Q., Mao, C., Wong, S. Y., Yang, Z. Y., Fu, X. H., Dai, X. Y., & Tang, J. L. (2015). Comparative Effectiveness and Safety of Monodrug Therapies for Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia: A Network Meta-analysis. Medicine, 94(27), e974. https://doi.org/10.1097/MD.0000000000000974
Carbone, A., Fuschi, A., Al Rawashdah, S. F., Al Salhi, Y., Velotti, G., Ripoli, A., Autieri, D., Palleschi, G., & Pastore, A. L. (2016). Management of lower urinary tract symptoms associated with benign prostatic hyperplasia in elderly patients with a new diagnostic, therapeutic, and care pathway. International Journal of Clinical Practice, 70(9), 734–743. https://doi-org.wilkes.idm.oclc.org/10.1111/ijcp.12849
Alcaraz, A., Carballido-rodríguez, J., Unda-urzaiz, M., Medina-lópez, R., Ruiz-cerdá, J.,L., Rodríguez-rubio, F., García-rojo, D., Brenes-bermúdez, F.,J., Cózar-olmo, J.,M., Baena-gonzález, V., & Manasanch, J. (2016). Quality of life in patients with lower urinary tract symptoms associated with BPH: change over time in real-life practice according to treatment–the QUALIPROST study. International Urology and Nephrology, 48(5), 645-656. https://dx.doi.org.wilkes.idm.oclc.org/10.1007/s11255-015-1206-7
At this point, if I successfully ruled out all possible explanations for the patient’s current condition, I would turn my focus to the Terazosin. Terazosin is a nonselective alpha 1 receptor antagonist which was originally developed as an antihypertensive agent. It has the ability to block a wide distribution of alpha receptors in the vascular and central nervous system which in elderly individuals can cause hypotension, fatigue, and dizziness (Yuan et al., 2015) A more appropriate choice based on the patient’s age and symptoms is Tamsolosin which has less effect on blood pressure possibly due to its higher selectivity for alpha 1 receptors (Woodard, 2016). It works by relaxing the muscles in the prostate and bladder allowing urine to flow easily. My recommendation is Tamsulosin 4mg, daily taken thirty minutes after eating NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
Next, a complete physical exam facilitates a correct diagnosis and should include a digital rectal exam (DRE) since there is suspected prostate involvement. Benign prostatic hyperplasia is a nonmalignant overgrowth of the prostate gland that is commonly seen in aging men. An enlarged prostate impairs the bladder’s ability to fully empty and contributes to LUTS (Carbone et al., 2016).
82-year-old male patient
Shun Zhang, Haoyan Tu, Jun Yao, Jianghua Le, Zhengxu Jiang, Qianqian Tang, Rongrong Zhang, Peng Huo, & Xiaocan Lei. (2020). Combined use of Diane-35 and metformin improves the ovulation in the PCOS rat model possibly via regulating the glycolysis pathway. Reproductive Biology and Endocrinology, 18(1), 1–11. https://doi.org/10.1186/s12958-020-00613-z
Moore, C. J., Perreault, M., Mottola, M. F., & Atkinson, S. A. (2020). Diet in Early Pregnancy: Focus on Folate, Vitamin B12, Vitamin D, and Choline. Canadian Journal of Dietetic Practice & Research, 81(2), 58–65. https://doi-org.ezproxy.fau.edu/10.3148/cjdpr-2019-025
Magee, L. A., & von Dadelszen, P. (2018). State-of-the-Art Diagnosis and Treatment of Hypertension in Pregnancy. Mayo Clinic Proceedings, 93(11), 1664–1677. https://doi.org/10.1016/j.mayocp.2018.04.03
Lundberg, G., & Mehta, L. (2018). Familial Hypercholesterolemia and Pregnancy. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2018/05/10/13/51/familial-hypercholesterolemia-and-pregnancy
Berry, D., Thomas, S., Dorman, K., Ivins, A., Abreu, M., Young L., & Boggess, K. (2018). Rationale, design, and methods for the medical optimization and management of pregnancies with overt Type 2 Diabetes (MOMPOD) study. BMC Pregnancy and Childbirth, 18(1), 1–12. https://doi-org.ezproxy.fau.edu/10.1186/s12884-018-2108-3
Finally, I would arrange a nutritional consult to teach suggested dietary pre-pregnancy recommendations. Additionally, effective methods for controlling cholesterol levels, since the majority of studies contraindicate the use of statins during pregnancy. According to Lundberg and Mehta, they are also known to have a teratogenic effect on the fetus (2018).
Next, my attention would focus on metformin. Traditionally, it is the treatment of choice outside of pregnancy (Berry et al., 2018). Interestingly, polycystic ovarian syndrome (PCOS) is known to cause infertility, and metformin in limited studies demonstrated an increase in fertility (Shun Zang et al., 2020). However, since there is insufficient research regarding its effects on mother and baby, the possible risks outweigh any benefit and it should be avoided. Additionally, I would recommend that when she becomes pregnant, switching to insulin is the preferred method for controlling blood sugar. According to Berry et al., it is proven to be the safest method for mother and baby (2018).
The primary care provider should begin with a thorough medical history, vital signs, a list of all prescription and non-prescription medications, and a physical exam. Since the patient is attempting to conceive, pre-pregnancy care is included to optimize the health of the mother and reduce any potential adverse effects to her, or her future baby NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
Module 3 Discussion
Subscribe
Augusta Ibeh posted Sep 16, 2020 10:26 PM
(A) QUESTION: Metformin has been effectively used for women with PCOS since they have pregnancy complications like abortion, gestational diabetes mellitus and high blood pressure. LW will be advised not to stop metformin once she is pregnant since evidence has shown that abrupt stopping of metformin during pregnancy might predispose the patient to pregnancy loss Johnson (2014). Buschur, E., & Kim, C. (2012, October). Guidelines and interventions for obesity during pregnancy. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151459/#:~:text=The revised guidelines also recommend,4] (Table 2).Johnson, N. P. (2014). Metformin use in women with polycystic ovary syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200666/ Terazosin hydrochloride (Hytrin)is an alpha-1-selective adrenoceptor blocking agent Abbott Laboratories (2009). Terazosin was approved by Food and Drug Administration (FDA) in 1987 for the treatment of high blood pressure and for the treatment of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia in 1993 in 1993 (Yang and Raja (2020). Other off label treatments of terazosin are used to the alleviation of nightmares linked with post-traumatic stress disorder and urinary tract stones Yang & Raja (2020). Common side effects of terazosin include; dizziness, headache, weakness, postural hypotension and nasal congestion, orthostatic hypotension, atrial fibrillation, anaphylaxis, intraoperative floppy iris syndrome but is rare Yang & Raja (2020). With these adverse side effects, Mr. GD who is 82 years old should be taking off of terazosin and alternative drug considered for the of his benign prostatic hyperplasia (BPH).ReferenceYang CH, Raja A. Terazosin. [Updated 2020 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545208/
View profile card for Augusta Ibeh
Last post Sep 20, 2020 9:53 PM by Augusta Ibe
Abbott Laboratories (2009) HYTRIN – terazosin hydrochloride tablet Abbott … https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019057s022lbl.pdf
Terazosin can be given at bedtime and patients instructed to get up slowly from the bed or chair to prevent fall related to orthostatic hypotension. Patients can be started on a low dosage and monitored to see how they will react to the drug.
Contraindication to terazosin include usage in geriatric population due to danger associated with syncope, postural hypotension can lead to falls, heart failure. All these will lead to increase mortality and morbidity among the elders Yang & Raja (2020).
As an antihypertensive, terazosin acts by blocking smooth muscles of the blood vessels and the anti-obstructive urinary tract (ureters, bladder, urethral sphincter) causing them to relax.
(B) QUESTION:
Kumar, P., & Khan, K. (2012). Effects of metformin use in pregnant patients with polycystic ovary syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3493830/#:~:text=Metformin has been shown to, problems like early pregnancy loss
Reference
LW will be advised to loss weight, childhood and adult obesity was noted to be increasing in the USA since 1980 Buchur and Kim (2012). This should be achieved through physical exercise, calorie reduction goals and use of structured meal plans. Obesity increases the risk to gestational diabetes, and this leads to both mother and fetus to complications such as gestational diabetes, high blood pressure, cesarean delivery, abortion, premature delivery, pre
