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The investigators concluded that deficiencies should be addressed by regular training that teaches the guidelines as they relate to pregnancy and stated erectile dysfunction help without pills buy viagra with dapoxetine visa, "even if a pregnant woman were to suffer cardiac arrest in front of a trained clinician erectile dysfunction doctor las vegas discount 50/30 mg viagra with dapoxetine otc, this might not improve her likelihood of survival erectile dysfunction age at onset order genuine viagra with dapoxetine, despite the existence of guidelines specifically for resuscitation in this population erectile dysfunction non organic buy viagra with dapoxetine 50/30 mg lowest price. A prospective, population-based, cohort study in the United Kingdom identified 60 cases matched with a control group. Large-bore intravenous access and arterial line placement are needed to treat and monitor hemorrhage and coagulopathy. Pressors such as phenylephrine and vasopressin and inotropes such as norepinephrine usually are needed to maintain a viable maternal hemodynamic status. In addition to providing a concentrated form of fibrinogen, cryoprecipitate is thought to provide fibronectin, which aids the reticuloendothelial system in the filtration of antigenic and particulate matter. Cardiac conditions usually require consultation and collaboration with a cardiologist who is knowledgeable about the physiologic changes caused by pregnancy and the impact of vaginal versus cesarean delivery. Advances in neonatology and pediatric cardiology have allowed increasing numbers of women with congenital cardiac lesions to reach their childbearing years. The physiology after palliative or corrective procedures can be quite complex, and consultation with a cardiologist who has experience with adult congenital cardiac disease patients is strongly recommended. Increased thrombotic tendencies during pregnancy may also lead to cardiac complications and make anticoagulation difficult to maintain for patients with mechanical heart valves. Discussion of individual lesions is beyond the scope of this chapter, but in general, stenotic valvular lesions and pulmonary hypertension do not respond well to the physiologic changes of pregnancy, which include increased intravascular volume, increased cardiac output, and increased heart rate (see Table 70-1). The highest-risk lesions are mitral and aortic stenosis, right-to-left intracardiac shunting, primary pulmonary hypertension or Eisenmenger syndrome,25 Marfan syndrome, and peripartum myocardial infarction. These lesions require highlevel involvement of a cardiologist familiar with her physiology and ongoing medical management. Decisions about timing and mode of delivery should be made in a setting that involves a multidisciplinary team of nurses, maternal-fetal medicine specialists or obstetricians, anesthesiologists, and cardiologists. There are risks and benefits to induction of labor and vaginal delivery and to scheduled elective cesarean delivery (Table 70-3). Hemabate (carboprost tromethamine), a synthetic prostaglandin analogue (prostaglandin F2), can increase pulmonary and systemic vascular resistance, as can methylergonovine (Methergine). Nifedipine, -agonists, magnesium boluses, and oxytocin boluses can reduce systemic vascular resistance, as can spinal and epidural techniques. All parenteral narcotics used for analgesia lead to hypercarbia, which can increase pulmonary vascular resistance. Depending on the cardiac physiology, these side effects can be beneficial or detrimental. Neuraxial analgesia and anesthesia are preferred unless the patient is extremely preload dependent or cannot tolerate a drop in systemic vascular resistance associated with local anesthetic sympathectomy. Lesions that may benefit from the preload and afterload reduction associated with neuraxial blocks are regurgitant valvular lesions, cardiomyopathies,28 and myocardial infarction. Occasionally, cardiac surgery may become necessary during pregnancy because medical management has failed. Cardiac surgery requiring bypass can be performed successfully during pregnancy, sometimes in conjunction with cesarean delivery when the pregnancy is in the third trimester. Reviews from two institutions recommend maintaining bypass pump flow rates greater than 2. Hemorrhage in the Peripartum Period Although many conditions can lead to hemorrhage in the peripartum period, the most commonly seen are uterine atony after delivery and placental abnormalities, including previa, accreta, percreta, and increta. Management of severe postpartum hemorrhage requires effective multidisciplinary teamwork to coordinate resuscitation of the patient and to identify and treat the cause of bleeding. A review of the Nationwide Inpatient Sample from 1995 through 2004 found that postpartum hemorrhage complicated 2. Logistic regression modeling identified age younger than 20 or older than 40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for uterine atony requiring transfusion, but risk factors were identified in only 39% of cases. When uterine atony occurs, the obstetric provider should mobilize other members of the labor and delivery teams, including anesthesiologists. The patient should be evaluated for hemodynamic stability and the need for analgesia to allow cooperation with obstetric maneuvers. If blood loss is ongoing, additional intravenous access should be obtained for volume replacement. If the patient does not have regional anesthesia in place and requires analgesia for obstetric maneuvers, intravenous fentanyl or ketamine may be given. If the patient is still in a labor room delivery setting, consider moving to the operating room in case general anesthesia is needed or more aggressive obstetric management is indicated. The anesthesiologist should be aware of the dose, route, and major side effects of the oxytocic drugs that can be used (Table 70-5). Oxytocin, methylergonovine, Hemabate, and misoprostol (Cytotec) should be available in the room. As the incidence of primary and repeat cesarean deliveries increases, so does the rate of placental abnormalities such as accreta, increta, and percreta. A woman with placenta previa and one or more previous cesarean deliveries should be evaluated for placenta accreta and delivered in a tertiary care medical center. Because of the need for many tertiary care services, maternal morbidity is reduced when delivery occurs in a hospital with blood bank capabilities, anesthesiology services available regardless of time or day, and ready access to surgical specialists. When the diagnosis of placenta accreta is made before rather than at delivery, blood loss and the need for transfusion are lower, and there is a higher rate of administration of steroids for fetal lung maturity. Invited attendees should include representatives from anesthesiology, nursing, maternal-fetal medicine, and neonatology and representatives from other services that may be needed in the operating room, such as gynecology, gynecologic oncology, urology, general surgery, vascular surgery, and interventional radiology. If possible, a member of the anesthesiology team should meet the patient during one of her antepartum obstetric visits to discuss the anesthesia plan and answer her questions about the perioperative management. Even if neuraxial anesthesia is planned for the case, she should be counseled about the need to convert to general anesthesia if major hemorrhage occurs.

A communication system should be in place to encourage early and ongoing contact between obstetric providers erectile dysfunction treatment gurgaon purchase viagra with dapoxetine 50/30mg line, anesthesiologists erectile dysfunction otc effective 100/60mg viagra with dapoxetine, and other members of the multidisciplinary team what medication causes erectile dysfunction order viagra with dapoxetine without a prescription. An ultrasound study should be performed early in the emergency room to determine gestational age and fetal viability erectile dysfunction drugs and glaucoma buy discount viagra with dapoxetine 100/60mg online, and fetal monitoring should be continued if the fetus is living and of a viable gestational age. Pregnancy should not alter any necessary evaluations or treatments for the mother. She should receive all needed diagnostic tests to optimize her management, with shielding for the fetus when possible. James D, Steer P, Weiner C, et al: Pregnancy and laboratory studies: a reference table for clinicians, Obstet Gynecol 114:1326, 2009. Grumebaum A, Chervenak F, Skupski D: Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events, Am J Obstet Gynecol 204:97, 2011. Dijkman A, Huisman C, Smit M, et al: Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training Knight M, Tuffnell D, Brocklehurst P, et al: Incidence and risk factors for amniotic-fluid embolism, Obstet Gynecol 115:910, 2010. Davies S: Amniotic fluid embolus: a review of the literature, Can J Anesth 48:88, 2001. Hidano G, Uezono S, Terui K: A retrospective survey of adverse maternal and neonatal outcomes for parturients with congenital heart disease, Int J Obstet Anesth 20:229, 2011. Sentilhes L, Ambroselli C, Kayem G, et al: Maternal outcome after conservative treatment of placenta accreta, Obstet Gynecol 115:526, 2010. Touboul C, Badiou W, Saada J, et al: Efficacy of selective arterial embolization for the treatment of life-threatening post-partum hemorrhage in a large population, Plos One 3:e3819, 2008. Shrivastava V, Nageotte M, Major C, et al: Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta, Am J Obstet Gynecol 197:402, 2007. Bishop S, Butler K, Monaghan S, et al: Multiple complications following the use of prophylactic internal iliac artery balloon catheterization in a patient with placenta percreta, Int J Obstet Anesth 20:70, 2011. Stotler B, Padmanabhan A, Devine P, et al: Transfusion requirements in obstetric patients with placenta accreta, Transfusion 51:2627, 2011. Wafaisade A, Maegele M, Lefering R, et al: High plasma to red blood cell ratios are associated with lower mortality rates in patients receiving multiple transfusion (4red blood cell units<10) during acute trauma resuscitation, J Trauma 70:81, 2011. Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central neuraxial blockades in Sweden 1990-1999, Anesthesiology 101:950, 2004. Visalyaputra S, Rodanant O, Somboonviboon W, et al: Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study, Anesth Analg 101:862, 2005. Keller C, Brimacombe J, Lirk P, et al: Failed obstetric tracheal intubation and postoperative respiratory support with the ProSeal(tm) laryngeal mask airway, Anesth Analg 98:1467, 2004. Royal College of Obstetricians and Gynaecologists: Thromboprophylaxis during pregnancy, labour and after normal vaginal delivery. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, Anesthesiology 118:251, 2013. Dellinger R, Levy M, Carlet J, et al: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008, Crit Care Med 36:296, 2008. Ramin S, Vidaeff A, Yeomans E, et al: Chronic renal disease in pregnancy, Obstet Gynecol 108:1531, 2006. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women: Committee opinion no. Meyer M, Wagner K, Benvenuto A, et al: Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy, Obstet Gynecol 110:261, 2007. Moore A, Costello J, Wieczorek P, et al: Gabapentin improves postcesarean delivery pain management: a randomized, placebocontrolled trial, Anesth Analg 112:167, 2011. American Society of Anesthesiologists Task Force on Obstetric Anesthesia: Practice guidelines for obstetric anesthesia: an updated report, Anesthesiology 106:843, 2007. The basic physiologic changes of pregnancy that must be understood for optimal management of critically ill obstetric patients are summarized in this chapter, and a more complete review can be found in Chapter 7. Direct obstetric deaths result primarily from peripartum hemorrhage, thromboembolic events, hypertensive disorders of pregnancy, and infectious complications. Indirect obstetric deaths arise from preexisting medical conditions that are aggravated by the physiologic perturbations of pregnancy, including cardiac disease, pulmonary disease, diabetes, and collagen vascular disease. Because these data are primarily collected from death certificates, some have suggested that the numbers underestimate the mortality rate by as much as 50%. Mortality rates declined significantly over the last century in the United States. Further complicating interpretation of this apparent increase over time is the fact that the period after delivery for defining a maternal mortality changed from 42 days to 90 days to 1 year in some jurisdictions, and it is not uniform across jurisdictions. Wide discrepancies in perinatal mortality rates exist among various ethnic populations, even when controlling for age and use of prenatal care. The highest maternal mortality rates occur in states with higher percentages of births for African-American women. Data on pregnancy-related mortality in the United States between 1998 and 2005 show a rate of 14. Only 13% occur in the antepartum period, and of these, 3% are related to an induced or spontaneous abortion. For approximately 15% of patients, the outcome is not known but likely follows a live birth. Obstetricdeathsarecausedbythromboembolicevents,hemorrhage, hypertension, infections, and preexisting medical conditions, such as diabetes, systemic lupus erythematosus, pulmonary disease, and cardiacdisease,whichmaybeaggravatedbythephysiologicchanges of pregnancy. The available critical care mortality scoring tools are imprecise for parturients and tend to overestimate mortality risks for critically ill gravidas. When a pregnant patient is in shock or suffering severe respiratory failure, her blood pressure should be measured using an indwelling arterial catheter.

As a result erectile dysfunction 23 years old generic viagra with dapoxetine 50/30mg on-line, it required a crew with a much higher skill level vacuum pump for erectile dysfunction in pakistan buy cheap viagra with dapoxetine 100/60 mg on line, able to cope with the vastly increased complexity of the controls and procedures required to fly safely erectile dysfunction video discount viagra with dapoxetine generic. One of the first flights ended soon after takeoff in a fiery crash that killed two members of the five-man crew erectile dysfunction drugs in the philippines purchase line viagra with dapoxetine. Subsequent investigations into the accident showed no mechanical failure but rather pilot error. Checklists use two strategies to improve care quality and reduce adverse outcomes in medicine. First, they aim to implement evidence-based and best-practice strategies in a systematic fashion, making their use routine and universal. Second, they attempt to improve the function of a team by creating a shared set of standards and goals. Investigators implemented a checklist for the insertion and care of central line catheters; at the end of the study, the unit that did not use checklists had no change in catheter-related bloodstream infections, whereas the intervention unit showed a decrease from 11 to 0 per 1000 catheter days, with an estimated savings of 43 catheter-related infections, eight lives, and nearly $2 million over 1 year. Application of this work to the surgical specialties has shown further remarkable results. A World Health Organization program implemented a 19-item surgical safety checklist in operating room facilities over 1 year in eight hospitals in a diverse range of health care settings. Checklists in Obstetrics Obstetrics is an excellent field for the development of safety checklists for quality improvement. A large portion of the adverse events in obstetrics are preventable events that occur in previously healthy patients. Labor and delivery units are typically challenged with a highly volatile patient load: It is very common for a unit to go from nearly empty to overfilled in the span of a few hours. The management of labor and delivery is also remarkable for long periods of waiting interrupted by rapid changes and sudden events. Extremes of volume and fluctuations in patient or unit severity status make the management of workloads difficult. Levels of team performance are seen to deteriorate during periods of low and high workload. Furthermore, checklists are designed to improve team communication by presenting specific topics for dialogue relating to patient care. The Joint Commission root-cause analyses have demonstrated that communication failures account for approximately 60% of sentinel events, 51% of reportable maternal events, and 68% of reportable perinatal deaths. Patient injury from an adverse drug event is the most common type of inpatient adverse event, and oxytocin, which is used in more than 50% of deliveries in High Risk zone Risk zone Performance Mod Low Boredom Comfort zone Work overload Very high Low Moderate High Workload Figure 49-2 Team performance as a function of workload. According to a survey of liability cases, approximately 50% of paid liability claims involve alleged misuse of oxytocin. When a cesarean delivery is planned, the prevention of neonatal morbidity hinges on the avoidance of iatrogenic prematurity. However, a systematic method, such as a preoperative checklist, to ensure that the fetus is not inadvertently delivered prematurely is rarely used. Preventable maternal morbidities include infection, thromboembolism, hemorrhage, and the risks related to anesthesia. There are many routine steps in the cesarean delivery process that are critical to lowering these risks. Without the use of perioperative antibiotics, the risks for endometritis and wound infection after cesarean delivery are as high as 40% and 15%, respectively. However, in a recent clinical trial, administration before incision decreased infectious morbidity by a further 60%. Adherence to these simple risk-reduction techniques can be encouraged and improved through the use of checklists. After implementation of checklists, performance improved and catheterrelated infections fell from 11 per 1000 to 0 per 1000. An emergent cesarean delivery occurs at an exceptionally brisk pace-rarely seen in other medical disciplines-usually in response to an acute hemorrhage, fetal bradycardia, umbilical cord prolapse, or uterine rupture. In most cases, this speed is for the benefit of the fetus or neonate, with a resulting increase in maternal risk for injury. Fetal bradycardia, for example, often requires swift action and depends on a carefully coordinated team. Fetal morbidity and mortality can be greatly affected by a delay of just a few minutes, and animal studies have demonstrated that brain injury can occur as early as 10 minutes into an event of severe asphyxia. Performance of an emergent cesarean delivery requires the coordination of at least six individuals: surgeon, skilled assistant for the surgery, anesthesiologist, scrub technologist, circulating nurse, and pediatrician or skilled pediatric caregiver. At present, there are no scripted or standardized protocols on how to conduct the emergency cesarean. Although the time from the diagnosis of an emergency to the delivery of the infant may not be appropriate for a checklist, the moment after delivery may provide a time for a team to regroup and reanalyze a situation to ensure all appropriate prophylactic and safety measures have been taken. Knowledge of national standards and guidelines and of the principles and practice of safety science is essential but not required, as these skill sets can be obtained while in the role, as long as the candidate is committed to lifelong learning. Project management skills are required to formulate and execute patient-centered safety initiatives. Communication skills and the ability to work collaboratively with the leadership team and staff members are desired traits of any leadership position. In addition, the ability to coordinate and provide interdisciplinary educational programs requires an acute understanding of the needs of the provider and the system in the complex setting of an obstetric service. To identify cases complicated by adverse outcomes and system weaknesses, the nurse may review various sources of information, such as anonymous event reporting systems (see next paragraphs) and labor and neonatal logs, which often contain Apgar scores and comments or concerns. A user-friendly Web-based system to track complications and identify patterns of adverse events may decrease underreporting.

Cardioversion can also be used to treat monomorphic ventricular tachycardia with a pulse present erectile dysfunction 22 cheap viagra with dapoxetine online. Of note erectile dysfunction young cure cheap viagra with dapoxetine online amex, digitalis-induced dysrhythmias are refractory to cardioversion erectile dysfunction natural remedies diabetes buy viagra with dapoxetine with a visa, and attempts at cardioversion in this situation could trigger more serious ventricular dysrhythmias erectile dysfunction causes std purchase viagra with dapoxetine canada. Digitalis-induced dysrhythmias should be treated by correction of acid-base status and electrolyte abnormalities, and administration of digitalis-binding antibody if needed. In patients with atrial fibrillation, cardioversion carries the risk of systemic embolization. Therefore, it is recommended that elective cardioversion be preceded by anticoagulation if the dysrhythmia has been present for longer than 48 hours. Before elective cardioversion, patients fast for at least 6 hours and electrolyte imbalances are corrected. Normally, elective cardioversion is performed under intravenous sedation-amnesia or very brief general anesthesia with standard monitoring. Radiofrequency Catheter Ablation In radiofrequency catheter ablation, an intracardiac electrode catheter inserted percutaneously under local anesthesia through a large vein (femoral, subclavian, internal jugular, or cephalic) is used to produce small, well-demarcated areas of thermal injury that destroy the myocardial tissue responsible for initiation or maintenance of dysrhythmias. Cardiac dysrhythmias amenable to radiofrequency catheter ablation include reentrant supraventricular dysrhythmias and some ventricular dysrhythmias. Radiofrequency catheter ablation is usually considered after pharmacologic therapy has failed or has not been tolerated by the patient. The procedure is usually performed under conscious sedation with routine monitoring. Permanently Implanted Cardiac Pacemakers the first successful human cardiac pacemaker implantation in the United States was performed in Buffalo, New York, by Dr. Permanent cardiac pacing was originally designed for the management of Stokes-Adams (syncopal) attacks in patients with complete heart block. Currently, the most common indication for permanent pacemaker insertion is sinus node dysfunction (sick sinus syndrome). Cardiac pacing is the only long-term treatment for symptomatic bradycardia regardless of cause. However, the basic components of an artificial cardiac pacemaker have not changed in over 50 years. These devices are made up of a pulse generator capable of producing electrical impulses, one or more sensing and pacing electrodes located in the right atrium and right ventricle, and a battery power source. Electrical impulses originating in the pulse generator are transmitted through specialized leads to excite endocardial cells and produce a propagating wave of depolarization in the myocardium. The lithium-iodide batteries used in pulse generators can last up to 10 years, but battery depletion requires surgical replacement of the entire pulse generator. The pulse generator for endocardial leads is usually implanted in a subcutaneous pocket below the clavicle. All implanted cardiac devices are designed to detect and respond to low-amplitude electrical signals. Many artificial cardiac pacemakers are designed to convert to an asynchronous mode rather than be completely inhibited when an external electrical field is encountered. Current flows from the negative pole (active lead) to stimulate the heart, then returns to the positive pole (the casing of the pulse generator). The current returns to the positive pole by traveling through myocardium to complete the circuit. In a bipolar lead system, there are two separate electrodes (positive and negative) in the same chamber in very close proximity to each other, so the distance the current travels to complete the circuit is very small, and hence there is very little chance that extraneous signals will intrude into or affect the lead circuit. The first letter denotes the cardiac chamber(s) being paced (A, atrium; V, ventricle; D, dual chamber). The second letter denotes the cardiac chamber(s) in which electrical activity is being sensed or detected (O, none; A, atrium; V, ventricle; D, dual). Current perioperative management of the patient with a cardiac rhythm management device. The fourth letter, R, denotes activation of rate response features, and the fifth position denotes the chamber(s) in which multisite pacing is delivered. This pacing mode can be used safely in patients with no intrinsic ventricular activity because there is no risk of the R-on-T phenomenon. The choice of pacing mode depends on the primary indication for the artificial pacemaker. This mode of pacing senses the native R wave, and if it is present, pacemaker discharge is inhibited (Figure 4-10). It is often used in patients with complete heart block with chronic atrial flutter or fibrillation, and in patients with long ventricular pauses. A factor to consider in the patient with a single-chamber ventricular pacemaker is the potential for pacemaker syndrome. Symptoms include syncope, weakness, lethargy, cough, orthopnea, paroxysmal nocturnal dyspnea, hypotension, and pulmonary edema. Single-Chamber Pacing Asynchronous Pacing Technical advances in cardiac pacing have included the creation of dual-chamber devices, rate-response algorithms, and implantable cardioverter-defibrillators with pacing capability. These advances have expanded the indications for cardiac pacing beyond symptomatic bradycardia to include neurogenic syncope, hypertrophic obstructive cardiomyopathy, and cardiac resynchronization therapy for congestive heart failure. Disorders such as neurocardiogenic syncope (resulting from carotid sinus hypersensitivity), vasovagal syncope, and hypertrophic cardiomyopathy can also be successfully treated with dual-chamber pacemakers. This improves cardiac output by maintaining the contribution of atrial systole to ventricular filling.

Sivojelezova A impotence with diabetes generic 50/30 mg viagra with dapoxetine amex, Shuhaiber S diabetes and erectile dysfunction causes generic 100/60mg viagra with dapoxetine visa, Sarkissian L diabetes and erectile dysfunction health generic 100/60mg viagra with dapoxetine fast delivery, et al: Citalopram use in pregnancy: prospective comparative evaluation of pregnancy and fetal outcome erectile dysfunction drugs over the counter uk buy 50/30mg viagra with dapoxetine mastercard, Am J Obstet Gynecol 193:2004, 2005. Kallen B, Otterblad Olausson P: Antidepressant drugs during pregnancy and infant congenital heart defect, Reprod Toxicol 21:221, 2006. Diav-Citrin O, Shechtman S, Weinbaum D, et al: Paroxetine and fluoxetine in pregnancy: a multicenter, prospective, controlled study, Reprod Toxicol 20:459, 2005. Isbister G, Dawson A, Whyte I, et al: Neonatal paroxetine withdrawal syndrome or actually serotonin syndrome It is most common for women to enter pregnancy already abusing or dependent on drugs. This chapter reviews the prevalence of drug abuse and dependence among individuals in the United States and discusses the uses and limitations of screening in women of reproductive age. Exposure to six different classes of drugs during pregnancy is then reviewed: tobacco, alcohol, marijuana, opioids, stimulants, and benzodiazepines. For each class of agent, the prevalence, pharmacology, screening, effects on maternal physiology and lactation, and effects on the fetus, neonate, and child are discussed, followed by treatment recommendations. The chapter concludes with a review of the current gaps in the research literature as they relate to clinical practice, and suggestions for future research. They are also at greater risk than men for past and current physical and sexual victimization and post-traumatic stress disorder. These disorders are best understood and treated in a context that acknowledges the myriad life challenges faced by drug-abusing or -dependent pregnant women. In the United States, there are an estimated 810,000 to 1 million chronic opioid (heroin) users and 6. Remarkably, 12% of 12- to 17-year-olds and 22% of 18- to 25-year-olds report prescription opioid abuse. The number of new initiates to opioid abuse has been steady over the past 7 years. Tracking these trends and their regional and local variations offers opportunities to understand and potentially reduce the problem of substance abuse and dependence in pregnancy. In addition to the alarming numbers of new and young drug initiates, the prevalence of substance use disorders is a concern. However, the prevalence data for adolescents suggest that the gender gap may be closing, primarily due to an increase among females (10.

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