In the postpartum period, secondary postpartum hemorrhage (SPPH) and endometritis are two conditions that frequently present to an obstetric triage unit. These complications may coexist and can occur from 24 hours postpartum to 6 weeks postdelivery. SPPH is typically not as severe as a primary bleeding episode. Postpartum women ultimately diagnosed with endometritis are generally stable, but less commonly can present in septic shock. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of secondary postpartum hemorrhage and postpartum endometritis. Prompt treatment of both SPPH and postpartum endometritis can reduce maternal morbidity and mortality. SPPH is managed with the same guiding principles as primary postpartum hemorrhage. Initial treatment for postpartum endometritis is intravenous clindamycin and gentamicin.

Pregnant women presenting with abdominal pain to an emergency department or obstetric triage setting frequently have a diagnostic ultrasound (US) to assess fetus, placenta, and adnexae. In the first trimester, symptomatic adnexal masses typically present with unilateral or bilateral pelvic cramping or pressure. Obtaining a history in a pregnant woman with abdominal pain is similar to doing so for the nonpregnant patient. In addition to routine cardiopulmonary examination, abdominal examination, and assessment for costovertebral angle tenderness, a sterile speculum and vaginal examination are performed to evaluate for adnexal or uterine tenderness, cervical dilation, and potential rupture of membranes. If a mass is suspected, US is the preferred imaging modality. Magnetic resonance imaging can be employed if additional imaging is needed. Differential diagnosis of abdominal pain in pregnant women must include other obstetric and nonobstetric causes of pain. This chapter describes clinical management and follow-up of pregnant women with adnexal masses.

Maternal sepsis is a common pregnancy-related condition; in the United States, it is a leading cause of maternal mortality, accounting for up to 28” of maternal deaths and up to 15” of maternal admissions to the intensive care unit. One contributing and modifiable factor to these deaths is failure to recognize sepsis, leading to delays in treatment. Therefore, rapid and accurate diagnosis and initial management of sepsis in pregnancy in the emergency department (ED) is paramount. Pregnancy poses a unique challenge given the baseline physiologic changes and the need to care for the mother while simultaneously caring for the fetus. Therefore, without clear pregnancy-specific data, recommendations are to follow the current guidelines for nonpregnant adults, yet be cognizant of the ways in which pregnancy may change maternal physiology and affect fetal well-being. Prompt identification and treatment of maternal sepsis will undoubtedly lead to the best possible maternal and neonatal outcomes.

Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants. All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, clinical management and follow-up care of IPV and sexual assault.

This chapter shows the importance, for older persons, of support groups. In spite of the changes that have occurred in the American family, and all the negative things that fill the popular press concerning family relationships, the family is still the backbone of support for most older people. To some extent, the type of family support older people obtain depends on whether they are living in the community or in an institutional setting such as a group home, retirement village, or nursing facility. Whether a person is married, has great impact on that person’s support within a family setting including emotional, financial, and physical support, particularly in times of illness or infirmity. The success of a second marriage depends to a considerable extent on the reaction of the adult children of the elderly couple. Older grandparents, no matter how motivated, can find caring for grandchildren to be very tiring.

Delirium, also known as acute confusional state, organic brain syndrome, brain failure, and encephalopathy, is a common occurrence among medical and surgical patients and causes extensive morbidity and mortality. This chapter provides an updated review of delirium, including pathophysiological correlates, clinical features, diagnostic considerations, and contemporary treatment options. The defining features of delirium include an acute change in mental status characterized by altered consciousness, cognition, and fluctuations. The chapter explores the risk factors for delirium. These can be divided into two categories: predisposing factors and precipitating factors. Imbalances in the synthesis, release, and degradation in gamma-aminobutyric acid (GABA), glutamate, acetylcholine, and the monoamines have also been hypothesized to have roles in delirium. GABA is the primary inhibitory neurotransmitter in the central nervous system (CNS) and medications such as benzodiazepines and propofol have known actions at GABA receptors and have been associated with delirium.

This chapter shows how the United States and the world are experiencing an aging evolution we are growing older. America is going through a revolution. As a whole, Americans are becoming older, and there are many more older people among people than ever before in our history. Obviously all cohorts of the population youth, young adults, middle-aged, young-old, oldest-old are heterogeneous. When some people think about the elderly as a whole, they picture frail, weak, dependent persons, some in nursing homes and many confined to their homes. The chapter demonstrates the differences the various age categories have in relation to selected chronic health conditions that cause limitations of activity. Widowhood is much more common for elderly American women than for older men. The aging of Baby Boomers will solidify the shift America is experiencing with the aging of its population. Centenarians make up a small percentage of the total U.S. population.

Primary progressive aphasia (PPA) is the term applied to a clinical syndrome characterized by insidious progressive language impairment that is initially unaccompanied by other cognitive deficits. This chapter describes several variants of PPA and more than one etiology. It explains three main variants of PPA, namely, semantic Variant of PPA (svPPA), nonfluent/agrammatic variant of PPA (nfvPPA) and logopenic variant of PPA (lvPPA), and also describes criteria for their diagnoses. The defining symptom of PPA is the presence of a language impairment for at least 2 years in the absence of any other significant cognitive problem. Assessment of other cognitive domains is challenging because many tests of memory, attention, executive functioning, and visual-spatial skills rely on language processes in some manner. There are no drug therapies proven to arrest progression of signs and symptoms of PPA due to frontotemporal lobar dementia (FTLD) or Alzheimer’s disease (AD) pathologies.

Dementia is an umbrella term for conditions such as Alzheimer’s disease (AD), dementia with Lewy bodies (DLB), vascular dementia (VaD), and frontotemporal dementia (FTD). Under that umbrella, FTD, also known as frontotemporal lobar degeneration (FTLD), can be further categorized to define a group of neurodegenerative disorders resulting from a progressive deterioration of the cells in the anterior temporal and/or frontal lobes of the brain. More specifically, ventromedial-frontopolar cortex is identified with metabolic impairment in FTD. This chapter elaborates on the history, epidemiology, pathophysiology, clinical features, treatment, and outcomes of FTD. The history and background section of each of the FTD categories highlights the evolution of the disease conceptualization. The FTD subtypes are conceptualized in three categories: neurobehavioral variant, motor variant, and language variant. The chapter illustrates the features of all three categories of FTD.

The concept of Mild cognitive impairment (MCI) makes a lot of sense in that individuals are typically not “normal” one day and “demented” the next. In theory, especially for progressive neurodegenerative conditions, such as Alzheimer’s disease (AD), frontotemporal dementia (FTD), the development of dementia may take months or years. The clinical syndrome of MCI due to AD can be identified via a neuropsychological evaluation or less-sensitive cognitive screening measures. Much of what we are learning about MCI, and therefore refining its diagnostic criteria, is coming from two large-scale studies of cognition and aging: Alzheimer’s Disease Neuroimaging Initiative (ADNI) and Australian Imaging, Biomarkers and Lifestyle (AIBL). According to the most recent research diagnostic criteria for MCI due to AD, evidence of beta-amyloid deposition, neuronal injury, and/or other biochemical changes needs to be seen to increase confidence of the etiology of MCI. Cholinesterase inhibitors remain the primary pharmacological treatment for AD.