SCI Flashcards
- 40 year old with hypertension on Clonidine and diabetes on insulin has erectile dysfunction. What is the best treatment?
A) discontinue HTN meds
B) papaverine injection
C) sexual counseling
Answer: A Antihypertensive medications can decrease libido and cause erectile dysfunction. Clonidine can be changed to another class of medications to see if side effects lessen. Diabetes can cause erectile dysfunction secondary to neuropathy. Papaverine is a non-specific smooth muscle relaxant which decreases resistance to arterial inflow and increases resistance to venous outflow. It is an intercavernous injection used in neurogenic erectile dysfunction. The use of papaverine as monotherapy has decreased due to it adverse effects (corporal fibrosis).
- Which muscle is tested for ASIA C5?
A) deltoid
B) biceps
C) brachioradialis
D) triceps
Answer: B
See chart below (question 10)
ASIA Motor Exam (for questions 9 & 10)
Level Muscle Level Muscle
C5: elbow flexors biceps/brachialis L2: hip flexors iliopsoas
C6: wrist extensors ECRL/ECRB L3: knee extensor quadriceps
C7: elbow extensor Triceps L4: ankle DF anterior tibialis
C8: 3rd DIP flexor FDP L5: 1st toe extensor EHL
T1: 5th digit abductor ADM S1: ankle PF gastroc/soleus
- Which muscle is tested for ASIA C6?
A) biceps
B) brachioradialis
C) triceps
D) extensor carpi radialis longus
Answer: D
ASIA Motor Exam (for questions 9 & 10)
Level Muscle Level Muscle
C5: elbow flexors biceps/brachialis L2: hip flexors iliopsoas
C6: wrist extensors ECRL/ECRB L3: knee extensor quadriceps
C7: elbow extensor Triceps L4: ankle DF anterior tibialis
C8: 3rd DIP flexor FDP L5: 1st toe extensor EHL
T1: 5th digit abductor ADM S1: ankle PF gastroc/soleus
Ref: Archives of PM&R 2002 Study Guide 83(3): S51
- What change is seen in muscle after 2 weeks of bed rest?
A) decreased number of myofibrils
B) atrophy of type II fibers
C) transformation of type I fiber into type II fibers
D) increase in number of sarcomeres
Muscle Fiber Types
Type I: slow twitch oxidative
low intensity, high endurance (i.e. postural muscles)
• low activity myosin ATPase
• slow speed of contraction
• less glycolytic capacity
• abundant mitochondrial enzymes for aerobic metabolism
• fatigue-resistant; suited for prolonged aerobic exercise
Type II: fast twitch oxidative/glycolytic
high intensity
• high activity myosin ATPase
• fast action potential transmission
• rapid calcium release and uptake by sarcoplasmic reticulum
• high rate cross-bridge turnover
Type IIa: fast twitch oxidative glycolytic
• fast contraction speed
• both aerobic and anaerobic capacity
Type IIb: fast twitch glycolytic
• greatest anaerobic potential
Ref: Braddom 2nd Edition: p 704-706; PT Secrets: p 8; PM&R Secrets: p 487
- A cognitively intact man with C2 ASIA A SCI states that he wants to die. What do you do?
A) tell him it is early and his full recovery potential is not yet known
B) have a family meeting
C) start anti-depressant medication
Answer: A (?)
There doesn’t seem to be enough information in this question but assuming that this scenario is referring to a patient soon after his injury, choice A would seem the most appropriate. As time elapses after the injury, choices B and C would be appropriate.
Ref: none
- What is seen in a wheelchair athlete who clamps his foley before a race?
A) increased BP
B) increased SV
C) increased CO
D) increased A-V O2 difference
Answer: A
Autonomic dysreflexia is an acute hypertensive syndrome with compensatory reduction in heart rate and contractility. Pounding headaches and sweating are often seen. Symptoms are due to a hyperactive reflex sympathetic discharge and is seen in patients with spinal cord lesions above T5-T6. Autonomic dysreflexia is caused by viscus distention or noxious stimuli below the level of the lesion (i.e. urologic obstruction, bowel impaction, infection, intra-abdominal process). Treatment includes identification and elimination of the cause (i.e. catherization, disempaction, treatment of infection). Immediate blood pressure reduction can also be treated with nitropaste or nifedipine.
Ref: PM&R Secrets, p 208, 475
- Which shoulder motions are not involved in wheelchair propulsion?
A) Adduction
B) Abduction
C) internal rotation
D) external rotation
Answer: A
Shoulders are abducted during wheelchair propulsion. Internal rotation and external rotation at the shoulder occur with forward and backward propulsion of the wheels, respectively.
Ref: none
- Long term use of Didronel can cause which of the following?
A) pathologic fracture
B) decrease mineralization following surgery
C) osteopenia
D) dissolve bone formed by HO
Answer: B Etidronate disodium (Didronel) is a bisphosphonate which inhibits growth of hydroxyapatite crystals by preventing the precipitation of calcium phosphate. It also slows the rate of osteoclastic and osteoblastic activity. It cannot dissolve any bone already formed by HO; however, may prevent recurrence of HO after resection (no good studies; radiation and NSAIDs more effective?). Didronel carries a potential risk of bone fracture secondary to osteomalacia when used for prolonged periods. It can also inhibit mineralization of bone after surgery.
Ref: PDR 2002: p 2888; Essentials of PM&R: p 574; PM&R Clinics of North America 1992: 3(2) p 411-413; Pocketpaedia: p 88
- A patient has absent sensation below T6 on th left and no motor function below T6 on the right. Where is the lesion?
A) left cord
B) right cord
C) cortex
Answer: B
Brown-Sequard syndrome is caused by a hemisection of the cord, resulting in ipsilateral mono/hemiparesis with contralateral pain and temperature sensation deficits. It is often caused by knife or gun shot wounds to the back or asymmetrically oriented spinal tumors. Prognosis for motor recovery is good.
Central cord syndrome results in weakness in the UE>>LE with preserved sacral sensation. There is LE hyperreflexia with UE mixed UMN/LMN changes. Causes include spinal stenosis secondary to extension injury, intramedullary hematoma / mass, or syrinx.
Anterior cord syndrome results in hyporeflexia, atrophy, variable motor loss, preservation of proprioception, but impaired pin prick and temperature sensation. Common causes include thoracolumbar burst fracture, AAA, and aortic clamping surgey with compromise to the artery of Adamkiewicz.
Posterior cord (dorsal column) syndrome results in bilateral deficits in proprioception. Potential causes include vitamin B12 deficiency often from pernicious anemia (subacute combined deficiency) and syphilis (tabes dorsalis).
Ref: PM&R Secrets: p 205-206
- What is the FIM score of a tetraplegic patient who can self-administer a suppository without help?
A) 6
B) 7
C) 4
D) 5
Answer: A
The bowel FIM score for the patient is a 6 (modified independent); although the suppository is administered independently, bowel evacuation requires the use of the suppository.
Functional Independence Measure (FIM)
Level of Function Score Definition
Independent 7 Complete independence. Task performed safely, without modifications, AD, and aids, and within a reasonable amount of time.
Independent 6 Modified independence. One of more of the following may be true: task requires AD, takes ↑ time, or there are safety issues.
Dependent 5 Supervision / setup. Requires more help than standby or cueing without physical contact, or setup.
Dependent 4 Minimal assistance. Patient expends more than 75% of effort.
Dependent 3 Moderate assistance. Patient expends 50-75% of effort.
Dependent 2 Maximal assistance. Patient expends 25-50% of effort.
Dependent 1 Total assistance. Patient expends less than 25% of effort.
Ref: Braddom 2nd Edition: p 5
?103. Prophylactic ABX use in SCI has been shown to decrease the incidence of which of the following?
Abx. Are generally reserved for persons symptomatic with fever and leukocytosis and for those demonstrating catheter blockage, increased spasticity, or very foul urine. Reference: Braddom, 2nd ed, pg 1256.
For those who have had indwelling Foley catheters for an extended period and require catheter removal oe exchange, ABX should be administered prophylactically before, during and afterremoval of the existing catheter. Gentamcin 80mg IM once just prior to removal of the catheter is appropriate for most pts. With stable renal function. Patients who demonstrate recurrent infections should be considered for suppressive treatment. Nitrofurantoin 50-100mg po BID is sufficient. Methanamine hippurate 1g TID and Ascorbic acid 500mg qd acidify the urine and are good for UTI prophylaxis.
Reference: PM&R Essentials, pg 634.
- What is the best type of anesthesia to give a pregnant C6 complete tetraplegia?
Answer- Spinal anesthesia is recommended during delivery for pts. with SCI at T6 or above.
- Vibroejaculatory stimulation and electrostimulation in the SCI male- know side effect?
Answer- Autonomic Dysreflexia
Vibratory stimulation of the glans penis has been used successfully by various groups to collect semen via antegrade and retrograde ejaculation (successful in about 50% SCI pts) as it requires an intact reflex arc. Ejaculatory success is better with high amplitude vibration. The advantages are noninvasiveness, home use, possibility of “natural fertilization, and that retrograde emission is less likely than with transrectal electrical stimulation. Improvement in quantity and quality of sperm with weekly use of vibratory ejaculatory technique may occur. The disadvantages are unpredictable response in many pts and the risk of autonomic dysreflexia.
Transrectal electrical stimulation or electroejaculation involves stimulation of the myelinated preganglionic efferent sympathetic fibers of the hypogastric plexus to obtain seminal emission into the posterior urethra. The semen is obtained from the posterior urethra by milking the urethral bulb and by catherization. Electroejaculation is an office or hospital based procedure b/c of the need to monitor for autonomic dyreflexia and the anoscopy performed to evaluate the rectal mucosa.
Reference: Braddom,2nd ed., pg 630.
- Which GI complication is most responsible for SCI pt 1 week post injury who develops nauseau and vomiting?
Answer- Gastroparesis- from high Ca
?107. Drugs of choice for radicular pain in SCI pts.?
Answer- Anticonvulsants
Could not find reference
?108. What is the first choice of to treat radicular pain in SCI pt.?
Answer- Neurontin
Could not find reference
- Paraplegic pt. recently given TLSO with n/v of meals. What do you do?
Answer- Turn pt. on right side
Superior mesenteric syndrome- syndrome in which the SMA compresses the third portion of the duodenum producing postprandial nausea, emesis, abdominal pain, distention and dehydration. It is exacerbated by being supine and spinal orthotics. Treatment includes small frequent meals, side lying and Reglan.
Reference: Kessler Notes 2003, Lecture 19, Tx of Acute SCI Pt. & Medical Complications.
- Which antibiotic class is indicated for a pregnant female with SCI and symptomatic UTI?
Answer- Cephalosporins
- Where is the most common location of osteoporosis in a young male T1 complete para who is wheelchair bound?
Answer- Proximal femur
The most measurable complication of osteoporosis following SCI is pathologic fracture. The historical incidence of fractures in the SCI population has been 1.45-6%; however, this historically low incidence may be deceptive since most SCI patients who sustain subsequent traumas and fractures are not treated in SCI centers. In addition, these studies on fractures have come from inpatient charts. Recently, the Model Spinal Cord Injury System has produced figures on fracture rates based on time following SCI, with incidences of 14% at 5 years, 28% at 10 years, and 39% at 15 years postinjury. These incidence rates are based on outpatient studies and have been confirmed.
The sites of fractures mimic the sites of greatest osteoporosis, with the supracondylar region and tibia being the most common. A bone mineral density fracture threshold of 50% appears to exist for the knee, and this most likely is the bone mineral density fracture threshold for most regions in the body.
Fracture rates in the lower extremities are 10 times greater in patients with complete SCI compared to patients with incomplete injuries. Paraplegic patients are at higher risk than tetraplegic patients, due to the higher level of function that paraplegic individuals have with increased mobility and participation in physical activities. Reference- E-Medicine, Osteoporosis and SCI.
Q171. Who is not a candidate for a phrenic nerve stimulator?
A) COPD
A) C2 SCI
B) Pt who is vent dependent
A. (given correct answer: A)
Phrenic nerve stimulation is a valuable adjunct in the care of the patient with ventilatory insufficiency who has a normal phrenic nerve, diaphragm, and lungs. Specifically, this technique is useful in persons with high level quadreplegia accompanied by respiratory paralysis and central hypoventilation syndromes.
Ref Braddom 2nd ed. 2000 p 476
Q219 Complications of electroejaculation
A) Autonomic dysreflexia
B) Infertility
C) Pain
D) Penile strictures
A (Correct answer is A)
Electroejaculation is the rhythmic delivery of current using a rectal probe to sympathetic efferent fibers. These techniques carry the risk of autonomic dysreflexia.
http://www.emedicine.com/orthoped/topic425.htm
Q 269. Know about immobilization hypercalcemia in SCI patient and SMA syndrome(? Didn’t find anything on SMA in SCI)
: Any form of immobilization alters calcium metabolism, but the structural and physiological changes associated with SCI predispose these patients to a variety of complications. These include hypercalcemia, bone fractures, nephrolithiasis, and renal failure. As early as 10 days post injury, hypercalciuria develops, reaching a peak between 1 and 6 months post injury. This calcium is derived from bone resorption, as increased levels of urinary phosphate, hydroxyproline, and glycosaminoglycans are also observed. There is an initial suppression of parathyroid hormone(PTH) that reaches its nadir at 3 months and returns to the normal range at 6 months. Pathological studies demonstrate an increased number of osteoclasts in bone, reaching a peak at 16 weeks post-injury, with diminished bone formation and mineralization.
Hypercalcemia is seen in some patients. Risk factors for hypercalcemia include childhood/adolescent SCI, male sex, complete injuries, tetraplegia, dehydration, and prolonged immobilization. Signs and symptoms of hypercalcemia include nausea, vomiting, abdominal pain, lethargy, apathy, fatigue, polydipsia, polyuria, muscle weakness, and anorexia. Mnemonic “stones, bones, and abdominal groans.” Treatment of hypercalcemia can include IV fluids, diuretics(ie furosemide), pamidronate, and calcitonin. Limitation of dietary calcium and Vitamin D intake is not recommended.
Ref: Braddom, PM&R, 2nd Edition, p 1249*, 709
PM&R Secrets, p.433
Q 281. Most common upper extremity injury in T-10 SCI from wheeling wheelchair(impingement, etc)?
A: Impingement Syndrome in shoulder…
Chronic shoulder impingement syndrome is a common injury in wheelchair users. It occurs when joint space between the humeral head (upper arm) and the acromioclavicular (A/C) shelf (top of the shoulder, at the end of the collarbone) decreases to the point where repeated contact occurs in the same spot on the supraspinatus tendon. This results in a pain, swelling, lesions and a reduction in the use of the shoulder joint. The most common factor of this condition is thought to be lack of joint stability. While joint stability is maintained by a combination of different bones and tissues, the most probable cause of the lack of stability is thought to be muscular imbalance (where some muscles are stronger or have greater endurance than others).
Ref: http://www.lerner.ccf.org/bme/bogert/lab/shoulder_stability.php Analysis of Shoulder Stability in Wheelchair User, J. Brems, M.D., Department of Orthopedic Surgery
440) What is the best type of anesthesia to give a pregnant C6 complete tetraplegia?
spinal anesthesia,
other answers:
pudendal block, stellate ganglion block, general anesthesia.
461) Which statement is true regarding marriage in SCI-injured women?
Rate of divorce is higher if married prior to SCI than post-SCI.
(Kreuter, SCI and Partner Relationships, Spinal Cord, Jan 2000)
318) The most common site for heterotopic ossification in SCI patients is at the
a) Shoulder
b) Elbow
c) Hip
d) Knee
C. In SCI, the incidence of HO is 20%, with most occurring in the hip region. The knee is also commonly affected. Garland DE. Clinical observations on fractures and heterotopic ossification in the spinal cord and traumatic brain injured populations. Clin Orthop. 1988 Aug;(233):86-101.
In TBI patients, HO involves the upper and lower extremities equally. The incidence of HO ranges from 11-76%, most commonly involving the shoulder, elbow, and hip, occurring infrequently at the knee. PM&R Secrets, 1997, p. 240.
Braddom includes the knees, although the incidence for each joint is not given in either reference.
335) An 18 year old man s/p MVA is now a C5 ASIA A tetraplegic. His family insists that you do NOT inform the patient of his diagnosis/prognosis, and threatens to sue if you do. How should you proceed?
a) Tell the patient immediately
b) Tell the patient at a more appropriate time
c) Obey the family’s wish and do not tell the patient
d) Call Risk Management
B. I cannot find evidence on this one, so here goes my explanation. There is no need to tell the patient immediately. On the other hand, the patient is an adult and your primary responsibility is to the patient, not the family. There is no need to call Risk Management at this time, as the family has no grounds for a lawsuit even if you told the patient immediately (although if it happened on 8GN you would be ordered to call STAT). The obvious answer is to wait until a more appropriate time, after the family has time to calm down and accept the reality of their relative’s situation. Bill Kane, 2004.
367) The ASIA classification of a SCI patient who can move his legs against gravity but not resistance with intact sacral sensation is
a) ASIA A
b) ASIA B
c) ASIA C
d) ASIA D
D. Based on the ASIA classification revised in 2000, the highest intact level (normal muscle strength or > 3/5 with the next level being normal) determines the level of injury. ASIA classification is based on completeness of injury. ASIA A indicates no motor or sensory preservation below the level of injury. ASIA B indicates sacral sparing. ASIA C is motor incomplete with more than half of the muscle groups below the level of injury with muscle grade < 3/5. ASIA D is also motor incomplete, wit hat least half of the muscle groups > 3/5. 2002 SAE-R Answer Key and Commentary on Preferred Choices, #115.
375) A patient with a C7 ASIA class A SCI should be independent with
a) Intermittent self-catheterization
b) Transfers
c) Ambulation on flat surfaces
d) Stair climbing
B. Persons with motor level C7 ASIA class A should be able to feed, dress, and bathe themselves using adaptive equipment and built-up utensils, independent with bed mobility, and level surface transfers, and should be able to propel a wheelchair outdoors. Independence in bowel and bladder function is generally seen with injury level at T1 and lower. 2003 SAE-R Answer Key and Commentary on Preferred Choices, #15.
390) Prophylactic antibiotic use in SCI patients has been shown to decrease the incidence of
a) Bacteruria
b) Pyelonephritis
c) Cystitis
d) Visits to the Columbia SCI clinic
B. I could not find evidence to support any of the choices given. Choosing a method of bladder management that minimizes the use of a foreign body, yet drains the bladder effectively, is the best available means to reduce the risk of UTI. The chief drawback to antimicrobial-coated catheters, topical or intravesicular antiseptic agents, and prophylactic oral antibiotics is that, over time, bacteria become resistant and overcome the obstacles to bladder invasion. Therefore, anti-infective catheter materials, antibiotics, and antiseptic agents are not beneficial for long-term prevention of UTI in persons with SCI. Novel approaches that avoid the use of antimicrobial agents offer hope for patients with recurrent UTI, but these techniques are still in the experimental stage. Trautner BW, Darouiche RO. Prevention of urinary tract infection in patients with spinal cord injury. J Spinal Cord Med. 2002 Winter; 25(4): 277-83.
374) A patient with a C5 ASIA class A SCI should be independent with
a) Feeding
b) Dressing
c) Transfers
d) Manual wheelchair propulsion
A. For persons with motor level C5, activities of daily living include drinking from a cup and feeding with static spoons and set-up, some oral/facial hygiene, writing and typing with equipment, and possibly some upper body dressing. At the C6 injury level, individuals are able to feed and perform upper body dressing with set-up and can perform level surface transfers with assistance. 2003 SAE-R Answer Key and Commentary on Preferred Choices, #15
392) The best choice for DVT prophylaxis in SCI patients is
a) Unfractionated heparin
b) Low molecular weight heparin
c) Coumadin
d) Ticlid
B. Initial experience with LMWH in SCI patients has demonstrated both an improved safety profile and superior thrombosis prevention when compared to earlier modes of treatment. LMWHs also exhibit better subcutaneous absorption, longer half-life (QD or BID dosing), and smoother anticoagulant response (do not reduce platelet activity or change vascular permeability). Braddom 2nd Ed, Ch. 55, p. 1252.
492.SCI male – what are side effects and nerve pathways involved in vibroejaculatory stimulation and electrostimulation?
Ans. These are techniques to restore fertility by restoring ejaculation in SCI males. Vibroejaculatory stimulation of the glans penis is used to collect semen. It is only successful in 50% of SCI males as it requires an intact reflex arc. Pathway involves stimulation of the pudendal nerve which results in contraction of the bulbocavernosus muscle leading to ejaculation. Success is better with high amplitude stimulation. Main disadvantage/side-effect is risk of autonomic dysreflexia. Advantages are noninvasiveness, home use, possibility of natural fertilization, and lower chance of retrograde emission.
Transrectal electrical stimulation or electroejaculation is the most common method of obtaining semen in the US. Can be obtained from 90% of patients. It involves stimulation of the myelinated preganglionic efferent sympathetic fibers of the hypogastric plexus to obtain seminal emission into the posterior urethra. Semen is then obtained by milking the urethral bulb and then catheterization. Disadvantage – decrease in sperm motility, more than in the case of vibratory stimulation. Also, it is an office/hospital based procedure.
Braddom, Chapter 30, page 630.
? 493.What is most common reason for young male para complete T6 has difficulty with self catheterization?
Ans. Increased sphincter spasm. I could not find a definitive answer to this. Complications with self cath in someone who is able to do it (C8 are independent in B/B care with setup, T1 completely independent) are sphincter spasm (managed with lubrication, local anesthetic gel, or coude catheter), urethral trauma, or stone formation. Best answer is most likely sphincter spasm.
Tan, Practical Manual of PM&R, Chapter 5.7, page 545.
- Elderly male has a fall and develops UE weakness >>> LE weakness, sphincter control and sensation intact. What is diagnosis (anterior cord, central cord, Brown-Sequard syndrome)
Ans. Central cord syndrome. Most common of the SCI clinical syndromes. Often associated with neck hyperextension injuries in elderly individuals with spondylosis. This is an incomplete injury, characterized by weakness more severe in arms than legs, with sparing of bladder and bowel function.
Braddom, Chapter 55 (SCI Medicine), page 1233.
- A C7 complete tetraplegic is independent with w/c mobility and transfers with sliding board. Which of the following is most responsible for his independence? (removable arm rests, pneumatic tires, etc )
Ans. Removable arm rests. This is necessary so patient can transfer from chair to bed and vice versa.
Braddom, Chapter 18 (prescription of WC’s), page 378
- Where would you expect a cord lesion in patient with absent bulbocavernosus reflex? (conus medullaris, cauda equina, T10 incomplete para, L4 complete para).
Ans. Conus medullaris. Bulbocavernosus reflex is a polysynaptic (S2-S4) sacral withdrawal reflex. Present in all normal individuals, and in SCI patients with lesions above the conus. Tested by squeezing glans and feeling contraction of anal sphincter muscle, or can be recorded objectively by stimulating dorsal nerve of penis and picking up EMG response in the anal sphincter muscle.
Secrets, Chapter 77 (urologic disorders in rehab), Pg. 474.
? 497. Which GI complication is most responsible for N/V in SCI patient 1 wk post injury? (decreased gastric emptying, increased gastric motility)
Ans. Decreased gastric emptying. Note: N/V can also be presenting sign of immobilization hypercalcemia, but this develops several weeks to few months after injury. Delayed gastric emptying is common in these patients and is a common cause of N/V. Constipation can also lead to n/v.
Braddom, Chapter 55, page 1257 (for general info, I could not fine a direct reference for which is MOST common)
- A patient with SCI has been on bowel regimen for 3 months and takes patient 3 hours to complete each day (maximum meds). What would be next most reasonable option?
Ans. Surgical management – colostomy. This offers independent bowel management, less incontinence, and decreased bowel care time.
Secrets, chapter 76 (neurogenic bowel), page 469
- SCI patient is prescribed a new abx to treat bacteuria and prevent pyelonephritis. What is the optimal experimental setup to test effectiveness of the drug in this single patient? (observational study, retrospective case report, randomized placebo controlled trial of single subject)?
Ans. Observational study. Randomized trial cannot be done with single subject, so observational study is best answer.
(I could not find a specific reference, but this seems the obvious choice).
- What is altered in PFT’s of a SCI patient when repositioned from sitting to supine position. (TLC, VC, RV, tidal volume)?
Ans. VC is increased when lying down in SCI. As opposed to other pulmonary conditions, patients with tetraplegia secondary to SCI exhibit higher vital capacities when lying down. This is related to improved diaphragmatic function as abdominal contents splint the lower rib cage. VC decreases when these patients sit upright, but can be countered to some extent by use of abdominal binder.
Braddom, Chapter 55, page 1248
- Which abx class is indicated for a pregnant female with a SCI and symptomatic UTI? (macrolides, cephalosporins, quinolones, Sulfa drugs)
Ans. Cephalosporins. The rest are pregnancy category C and should be avoided in pregnant women.
Pharmacopoeia
