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Miscarriage

(Spontaneous Abortion)

Medical Author: Melissa Conrad Stöppler, MD


Medical Editor: William C. Shiel, Jr., MD, FACP, FACR

 What is a miscarriage?

 What causes a miscarriage, and what are the tests for the different causes?

 What does NOT cause miscarriage?

 Are there lifestyle factors associated with miscarriage?

 What are the symptoms of a miscarriage?

 What will the doctor look for during an examination with suspected miscarriage?

 How is threatened abortion evaluated?

 What are common terms a woman might hear during evaluation for miscarriage?

 What treatment can a woman expect when she has had a miscarriage?

 When should a woman receive evaluation for underlying causes of pregnancy loss?

 Can something be done to prevent future miscarriages?

 Miscarriage At A Glance

Miscarriage

Miscarriage Symptoms and Signs

If you are having a spontaneous miscarriage, you will probably have vaginal bleeding, abdominal
pain, and cramping.

 Bleeding may be only slight spotting, or it can be quite severe. Your health care practitioner
will ask about how much you have bled-usually the number of pads you've soaked through.
You will also be asked about blood clots or whether you saw any tissue.

 Pain and cramping occur in the lower abdomen. They may occur on only one side, both
sides, or in the middle. The pain can also go into your lower back, buttocks, and genitals.

 You may no longer have signs of pregnancy such as nausea or breast swelling/tenderness if
you have experienced a miscarriage.

Read more about symptoms of a miscarriage »

What is a miscarriage?
A miscarriage is any pregnancy that ends spontaneously before the fetus can survive. A miscarriage
is medically referred to as a spontaneous abortion. The World Health Organization defines this
unsurvivable state as an embryo or fetus weighing 500 grams or less, which typically corresponds to
a fetal age (gestational age) of 20 to 22 weeks or less. Miscarriage occurs in about 15% to 20% of all
recognized pregnancies, and usually occurs before the 13th week of pregnancy. With the
development of highly sensitive assays for hCG levels that can detect an early pregnancy even prior
to the expected next period (menstruation), researchers have been able to show that around 60% to
70% of all pregnancies (recognized and unrecognized) are lost. Because the loss occurs so early,
many miscarriages occur without the woman ever having known she was pregnant. Of those
miscarriages that occur before the eighth week, 30% have no fetus associated with the sac or
placenta. This condition is called blighted ovum, and many women are surprised to learn that there
was never an embryo inside the sac.

As described above, some miscarriages occur before women recognize that they are pregnant.
About 15% of fertilized eggs are lost before the egg even has a chance to implant (embed itself) in
the wall of the uterus. A woman would not generally identify this type of miscarriage. Another 15%
of conceptions are lost before eight weeks' gestation. Once fetal heart function is detected in a given
pregnancy, the chance of miscarriage is less than 5%.

A woman who may be showing the signs of a possible miscarriage (such as vaginal bleeding) may
have her pregnancy referred to as a "threatened abortion."

What causes a miscarriage, and what are the tests for the different causes?

The cause of a miscarriage cannot always be determined. The most common known causes of
miscarriage in the first third of pregnancy (1st trimester) are chromosomal abnormalities, collagen
vascular disease (such as lupus), diabetes, other hormonal problems, infection, and congenital
(present at birth) abnormalities of the uterus. Chromosomal abnormalities of the fetus are the most
common cause of early miscarriages, including blighted ovum (see above). Each of the causes will be
described below.

Chromosomal abnormalities

Chromosomes are microscopic components of every cell in the body that carry all of the genetic
material that determines hair color, eye color, and our overall appearance and makeup. These
chromosomes duplicate themselves and divide many times during the process of development, and
there are numerous points along the way where a problem can occur. Certain genetic abnormalities
are known to be more prevalent in couples that experience repeated pregnancy losses. These
genetic traits can be screened for by blood tests prior to trying to conceive.

Half of the fetal tissue from1st trimester miscarriages contain abnormal chromosomes. This number
drops to 20% with 2nd trimester miscarriages. In other words, abnormal chromosomes are more
common with 1st trimester than with 2nd trimester miscarriages. First trimester miscarriages are so
very common that unless they occur more than once, they are not considered "abnormal" per se.
They do not prompt further evaluation unless they occur more than once. In contrast, 2nd trimester
miscarriages are more unusual, and therefore may trigger evaluation even after a first occurrence. It
is therefore clear that causes of miscarriages seem to vary according to trimester.
Chromosomal abnormalities also become more common with aging, and women over age 35 have a
higher rate of miscarriage than younger women. Advancing maternal age is the most significant risk
factor for early miscarriage in otherwise healthy women.

Collagen vascular diseases

Collagen vascular diseases are illnesses in which a person's own immune system attacks their own
organs. These diseases can be potentially very serious, either during or between pregnancies. In
these diseases, a woman makes antibodies to her own body's tissues. Examples of collagen vascular
diseases associated with an increased risk of miscarriage are systemic lupus erythematosus, and
antiphospholipid antibody syndrome. Blood tests can confirm the presence of abnormal antibodies
and are used in the diagnose of these conditions.

Diabetes

Diabetes generally can be well managed during pregnancy, if a woman and her health care
practitioner work closely together. However, if the diabetes is insufficiently controlled, not only is
the risk of miscarriages higher, but the baby can have major birth defects. Other problems can also
occur in relation to diabetes during pregnancy. Good control of blood sugars during pregnancy is
very important.

Hormonal factors

Hormonal factors may be associated with an increased risk of miscarriage, including Cushing's
Syndrome, thyroid disease, and polycystic ovary syndrome (PCOS). It also has been suggested that
inadequate function of the corpus luteum in the ovary (which produced progesterone necessary for
maintenance of the very early stages of pregnancy) may lead to miscarriage. Termed "luteal phase
defect," this is a controversial issue, since several studies have not supported the theory of luteal
phase defect as a cause of pregnancy loss.

Infections

Maternal infection with a large number of different organisms has been associated with an
increased risk of miscarriage. Fetal or placental infection by the offending organism then leads to
pregnancy loss. Examples of infections that have been associated with miscarriage include infections
by Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex,
cytomegalovirus, and lymphocytic choriomeningitis virus.

Abnormal structural anatomy

Abnormal anatomy of the uterus can also cause miscarriages. In some women there can be a tissue
bridge (uterine septum), that acts like a partial wall dividing the uterine cavity into sections. The
septum usually has a very poor blood supply, and is not well suited for placental attachment and
growth. Therefore, an embryo implanting on the septum would be at increased risk of miscarriage.

Other structural abnormalities can result from benign growths in the uterus called fibroids. Fibroid
tumors (leiomyomata) are benign growths of muscle cells in the uterus. While most fibroid tumors
do not cause miscarriages, (in fact, they are a rare cause of infertility), some can interfere with the
embryo implantation and the embryo's blood supply, thereby causing miscarriage.
Other causes

Invasive surgical procedures in the uterus, such as amniocentesis and chorionic villus sampling, also
slightly increase the risk of miscarriage

What does NOT cause miscarriage?

It must be emphasized that exercise, working, and sexual intercourse do not increase the risk of
pregnancy loss in routine (uncomplicated) pregnancies. However, in the unusual circumstance
where a woman is felt by her physician to be at higher risk of spontaneous abortion, she may be
advised to stop working and refrain from having sexual intercourse. Women with past history of
premature delivery and other specific obstetrical conditions might fall under this category.

Are there lifestyle factors associated with miscarriage?

Smoking more than 10 cigarettes per day is associated with an increased risk of pregnancy loss, and
some studies have even shown that the risk of miscarriage increases with paternal smoking. Other
factors, such as alcohol use, fever, use of nonsteroidal anti-inflammatory drugs around the time of
embryo implantation, and caffeine use have all been suggested to increase the risk of miscarriage,
although more studies are needed to fully clarify any potential risks associated with these factors. Of
course, alcohol is a known teratogen (a chemical that can damage the developing fetus), so pregnant
women are advised to abstain from drinking alcoholic beverages.

What are the symptoms of a miscarriage?

Cramping and vaginal bleeding are the most common symptoms noticed with spontaneous abortion.
The cramping and bleeding may be very mild, moderate, or severe. There is no particular pattern as
to how long the symptoms will last.

Vaginal bleeding during early pregnancy is often referred to as a "threatened abortion." The term
threatened abortion is used since miscarriage does not always follow vaginal bleeding in early
pregnancy, even after repeated episodes or large amounts of bleeding. Studies have shown that 90%
to 96% of pregnancies with demonstrated fetal cardiac activity that result in vaginal bleeding at 7 to
11 weeks of gestation will result in an ongoing pregnancy.

What will the doctor look for during an examination with suspected miscarriage?

A woman's cervix might have some bloody discharge, but nothing else unusual will be characteristic
of threatened abortion. Some women will have mild uterine tenderness during the manual
examination of the uterus. The doctor may look to see if the cervix is dilated and will check to see if
the uterus is enlarged to an extent appropriate for gestational age of the pregnancy.

How is threatened abortion evaluated?

Pelvic ultrasound is used to visualize fetal heartbeat and to determine whether a pregnancy is still
viable. The ultrasound examination can also distinguish between intrauterine and ectopic
pregnancies. The doctor may also order blood levels of serial human chorionic gonadotrophin (HCG)
to help determine the viability of a pregnancy if the ultrasound examination is not conclusive. During
the evaluation, the woman may be advised to rest and avoid sexual intercourse (activity).
What are common terms a woman might hear during evaluation for miscarriage?

1. "Miscarriage" (spontaneous abortion) is termination of pregnancy before the fetus is viable


(able to survive).

2. "Complete abortion" describes spontaneous (not intentionally induced by medication or


procedures) passage of all fetal and placental tissue. This is common prior to 12 weeks'
gestation.

3. "Incomplete abortion" is when some, but not all, the fetal and placental tissue is expelled.

4. "Products of conception" refers to the combination of fetal and placental tissue.

5. "Threatened abortion" is when a miscarriage does not actually occur, but there is vaginal
bleeding from the uterus. The cervix will not be dilated and does not show signs of imminent
passage of fetal and placental tissue.

6. "Missed abortion" describes a fetal death in the uterus prior to viability, but the products of
conception are not passed.

7. A "septic (infectious) abortion" is caused by bacterial infection and accompanied by fever,


chills, pain, and a pus-containing discharge

What treatment can a woman expect when she has had a miscarriage?
The central goal of the doctor in this situation will be to try to figure out whether the woman
has passed all of the tissue from the fetus and placenta. If she has passed all the tissue, she
may only require observation by medical personnel. On the other hand, a woman who has not
passed all of the tissue (incomplete abortion) will usually need suction dilation and curettage
(D&C) of the uterus to remove any retained products of the pregnancy. This procedure is
done with local anesthesia, and sometimes antibiotics may be prescribed for the woman to
prevent infection.

When should a woman receive evaluation for underlying causes of pregnancy loss?
Currently, most practitioners will not initiate an extensive medical evaluation for a single
pregnancy loss, since the chance of having a normal pregnancy subsequent to even two
consecutive miscarriages is 80% to 90%. For women with recurrent pregnancy loss, an
evaluation will focus on the pattern and history of the prior miscarriages. Three consecutive
miscarriages would suggest a woman should receive further evaluation.

Thus, the following tests are considered for women with three consecutive miscarriages.

Blood testing can be ordered to identify chromosomal abnormalities in the couple that could
be transmitted to the fetus. The couple can each appear completely normal but still carry
chromosomal defects, which, when combined, can be lethal to the embryo. This type of
testing is called karyotyping, and it is performed on both members of the couple. A
hysterosalpingogram (HSG) can identify anatomical abnormalities within the uterus.
Antinuclear antibody, anticardiolipin antibody, VDRL, RPR, and lupus anticoagulant are
some of the blood tests used to diagnose autoimmune diseases that can cause recurrent
miscarriage.

As described above, some of these illnesses will already by apparent to the woman and her
doctor, but not all cases. Other antibody tests may be performed as well.

Can something be done to prevent future miscarriages?

The treatment of recurrent miscarriage depends on what is believed to be the underlying cause. This
often is not as simple as it sounds. Careful evaluation may turn up several potential factors which
alone or together may be responsible for the pregnancy losses. If a chromosomal problem is found
in one or both persons, then counseling as to future risks is the only option for the couple, since
there is currently no method to correct genetic problems.

If a structural problem is encountered with the uterus, surgical correction could be contemplated. It
should be emphasized that just because a structural abnormality is found, it does not necessarily
mean that it caused the miscarriage. Removal of a fibroid or uterine septum does not guarantee a
future successful pregnancy, since the fibroid or uterine septum may not have been the cause of
miscarriage in the first place.

Adequate control of diabetes and thyroid disease is critical in trying to prevent recurrent pregnancy
loss in women with those conditions. For women with immunologic problems, such as such as
systemic lupus erythematosus and antiphospholipid antibody syndrome, certain medications are
being studied that may be useful in achieving successful pregnancy outcomes. Blood thinners such as
aspirin and heparin can, in some cases, prevent further pregnancy loss.

The use of progesterone to increase the blood levels of this hormone is sometimes used for patients
with recurrent pregnancy loss, although large-scale controlled studies that confirm the utility of
progesterone supplementation have not been carried out. However, many physicians report success
with progesterone therapy. Progesterone may be given as vaginal suppositories, or in tablet or gel
form.

In dealing with recurrent pregnancy loss, it is important to realize that even though apparently
obvious problems can be corrected, a miscarriage can still occur. This is not to say that attempts
should not be taken to correct identified abnormalities that have been historically associated with
miscarriage. However, no treatment can be guaranteed. Even with repeated miscarriages, there is
still a very good chance of achieving a successful pregnancy. Early pregnancy and pre-pregnancy
counseling can help identify risk factors and allow the practitioner to provide any special care that
may be needed.

Miscarriage At A Glance

 Spontaneous miscarriage is the loss of a pregnancy that ends spontaneously before the fetus
can survive.

 Exercise, working, and intercourse do NOT increase risk of miscarriage for women without
underlying specific medical conditions that place them at risk.
 Causes for miscarriage include genetic abnormalities, infection, medications, hormonal
effects, structural abnormality of the uterus, and immune abnormalities.

 After an isolated miscarriage, the chance of having a normal term pregnancy in the future is
near 90%.

 Treatment of recurrent miscarriage is directed toward the underlying cause

Medications and Drugs


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Nonsteroidal Antiinflammatory Drugs (NSAIDs)


Medical Author: Omudhome Ogbru, Pharm.D.
Medical Editor: Jay Marks, M.D.

 What are NSAIDs and how do they work?


 For what conditions are NSAIDs used?
 Are there any differences between NSAIDs?
 What are the side effects of NSAIDs?
 With which drugs do NSAIDs interact?
 What NSAIDS are approved in the United States?

What are NSAIDs and how do they work?


Prostaglandins are a family of chemicals that are produced by the cells of the body and have
several important functions. They promote inflammation, pain, and fever; support the blood
clotting function of platelets; and protect the lining of the stomach from the damaging effects
of acid.

Prostaglandins are produced within the body's cells by the enzyme cyclooxygenase (COX).
There are two COX enzymes, COX-1 and COX-2. Both enzymes produce prostaglandins that
promote inflammation, pain, and fever. However, only COX-1 produces prostaglandins that
support platelets and protect the stomach. Nonsteroidal antiinflammatory drugs (NSAIDs)
block the COX enzymes and reduce prostaglandins throughout the body. As a consequence,
ongoing inflammation, pain, and fever are reduced. Since the prostaglandins that protect the
stomach and support platelets and blood clotting also are reduced, NSAIDs can cause ulcers
in the stomach and promote bleeding.

For what conditions are NSAIDs used?


NSAIDs are used primarily to treat inflammation, mild to moderate pain, and fever. Specific
uses include the treatment of headaches, arthritis, sports injuries, and menstrual cramps.
Ketorolac (Toradol) is only used for short-term treatment of moderately severe acute pain
that otherwise would be treated with opioids. Aspirin (also an NSAID) is used to inhibit the
clotting of blood and prevent strokes and heart attacks in individuals at high risk. NSAIDs
also are included in many cold and allergy preparations.

Are there any differences between NSAIDs?


NSAIDs vary in their potency, duration of action, how they are eliminated from the body,
how strongly they inhibit COX-1 and their tendency to cause ulcers and promote bleeding.
The more an NSAID blocks COX-1, the greater is its tendency to cause ulcers and promote
bleeding. One NSAID, celecoxib (Celebrex), blocks COX-2 but has little effect on COX-1,
and is therefore further classified as a selective COX-2 inhibitor. Selective COX-2 inhibitors
cause less bleeding and fewer ulcers than other NSAIDs.

Aspirin is a unique NSAID, not only because of its many uses, but because it is the only
NSAID that inhibits the clotting of blood for a prolonged period (4 to 7 days). This prolonged
effect of aspirin makes it an ideal drug for preventing blood clots that cause heart attacks and
strokes.

Most NSAIDs inhibit the clotting of blood for only a few hours. Ketorolac (Toradol) is a very
potent NSAID and is used for moderately severe acute pain that usually requires narcotics.
Ketorolac causes ulcers more frequently than other NSAID. Therefore, it is not used for more
than five days. Although NSAIDs have a similar mechanism of action, individuals who do
not respond to one NSAID may respond to anothe

What are the side


effects of NSAIDs?

NSAIDs are
associated with
several side effects.
The frequency of
side effects varies
among NSAIDs. The
most common side
effects are nausea,
vomiting, diarrhea,
constipation,
decreased appetite,
rash, dizziness,
headache, and
drowsiness. NSAIDs
may also cause fluid <script language="JavaScript1.2" type="text/javascript"
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liver failure, ulcers
and prolonged
bleeding after an
injury or surgery.
From WebMD
Some individuals
Migraines and Headaches Resources
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NSAIDs and may  9 Childhood Illnesses: Beware of These
develop shortness
of breath when an  Got Tooth Pain? Try These Fixes
NSAID is taken.
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People with asthma
are at a higher risk  Which Foods Are Highest in Fiber?
for experiencing
serious allergic  How Bad Is Your Diet? Assess Yourself
reaction to NSAIDs.
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Individuals with a
serious allergy to Health Solutions From Our Sponsors
one NSAID are likely
to experience a  Depression Med for You?
similar reaction to a
 Fibromyalgia Center
different NSAID.
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Use of aspirin in
children and
teenagers with
chickenpox or
influenza has been Related Drugs - WebMD Health Network
associated with the
 Ibuprofen Oral - WebMD
development of
Reye's syndrome.
Therefore, aspirin
and non-aspirin
salicylates [for Also on MedicineNet
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 Living with Obstructive Asthma
(Amigesic)] should
not be used in  Trouble Breathing? Take the COPD Health Check
children and
teenagers with
suspected or
confirmed
chickenpox or
influenza.

NSAIDs may
increase the risk of
potentially fatal,
stomach and
intestinal adverse
reactions (for
example, bleeding,
ulcers, and
perforation of the
stomach or
intestines). These
events can occur at
any time during
treatment and
without warning
symptoms. Elderly
patients are at
greater risk for
these adverse
events. NSAIDs
(except low dose
aspirin) may
increase the risk of
potentially fatal
heart attacks,
stroke, and related
conditions. This risk
may increase with
duration of use and
in patients who
have underlying risk
factors for heart
and blood vessel
disease. NSAIDs
should not be used
for the treatment of
pain resulting from
coronary artery
bypass graft (CABG)
surgery.

With which drugs


do NSAIDs interact?

NSAIDs reduce
blood flow to the
kidneys and
therefore reduce
the action of
diuretics and
decrease the
elimination of
lithium (Eskalith)
and methotrexate
(Rheumatrex).

NSAIDs also
decrease the ability
of the blood to clot
and therefore
increase bleeding.
When used with
other drugs that
also increase
bleeding [for
example, warfarin
(Coumadin)], there
is an increased
likelihood of serious
bleeding or
complications of
bleeding. Therefore,
individuals who are
taking drugs that
reduce the ability of
blood to clot should
avoid prolonged use
of NSAIDs.

Nonsteroidal
antiinflammatory
drugs also may
increase blood
pressure in patients
with hypertension
(high blood
pressure) and
therefore
antagonize the
action of drugs that
are used to treat
hypertension.

What NSAIDS are


approved in the
United States?

The complete list of


approved NSAIDs is
very long. The
following list
contains only
NSAIDs that are
commonly used:

 aspirin

 celecoxib
(Celebrex)

 diclofenac
(Voltaren)

 diflunisal
(Dolobid)

 etodolac
(Lodine)

 ibuprofen
(Motrin)

 indomethaci
n (Indocin)

 ketoprofen
(Orudis)

 ketorolac
(Toradol)

 nabumeton
e (Relafen)

 naproxen
(Aleve,
Naprosyn)

 oxaprozin
(Daypro)

 piroxicam
(Feldene)
 salsalate
(Amigesic)

 sulindac
(Clinoril)

 tolmetin
(Tolectin)

Reference: FDA
Prescribing
Information

Last Editorial
Review: 12/17/2008

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Medications and Drugs

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GENERIC NAME: NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID) - ORAL

Medication Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes |
Missed Dose | Storage

USES: This medication is used to treat pain and reduce inflammation. It is used to treat headaches,
muscle aches, dental pain, menstrual cramps, arthritis, or athletic injuries. Some NSAIDs are also
used to reduce fever.
HOW TO USE: Take this medication by mouth with a full glass (8oz or 240ml) of water unless your
doctor directs you otherwise. The dosage is based on your medical condition and response to
therapy. If stomach upset occurs while taking this medication, take it with food, milk, or an antacid.
Do not lie down for at least 30 minutes after taking this drug. In certain conditions (e.g., arthritis), it
may take up to two weeks, taken regularly, before the full benefit of this drug takes effect. If you use
this for migraine headache, and the pain is not relieved or it worsens after the first dose, seek
immediate medical attention.

SIDE EFFECTS: Upset stomach, nausea, vomiting, heartburn, headache, diarrhea, constipation,
drowsiness, and unusual fatigue may occur. If any of these effects persist or worsen, notify your
doctor. Tell your doctor immediately if any of these serious side effects occur: stomach pain,
swelling of the feet or ankles, ringing in the ears (tinnitus). Tell your doctor immediately if any of
these unlikely but serious side effects occur: vision changes, joint pain, muscle pain or weakness,
easy bruising or bleeding, persistent sore throat and fever. Tell your doctor immediately if any of
these highly unlikely but very serious side effects occur: changes in amount or color of urine,
yellowing of the eyes or skin. If you notice any of the following unlikely but serious side effects, stop
taking this medication and consult your doctor or pharmacist immediately: black stools, persistent
stomach/ abdominal pain, vomit that looks like coffee grounds. An allergic reaction to this drug is
unlikely, but seek immediate medical attention if it occurs. Symptoms of an allergic reaction include:
rash, itching, swelling, dizziness, trouble breathing. If you notice other effects not listed above,
contact your doctor or pharmacist

PRECAUTIONS: Tell your doctor your medical history, especially of: kidney problems, liver problems,
stomach problems (e.g., ulcers), heart disease (e.g., arrhythmias, heart failure), high blood pressure
(hypertension), diabetes, blood problems (e.g., anemia, bleeding disorders, porphyria), asthma,
nasal polyps, eye problems, severe or long-lasting headaches, any allergies - especially aspirin/NSAID
allergy (e.g., ibuprofen, celecoxib). This drug may make you dizzy or drowsy. Use caution engaging in
activities requiring alertness such as driving or using machinery. Limit alcoholic beverages. This
medication may make you more sensitive to the sun. Avoid prolonged sun exposure, use a
sunscreen, and wear protective clothing when outdoors. This medicine may cause stomach bleeding.
Daily use of alcohol and this medicine may increase your risk for stomach bleeding. Caution is
advised when using this drug in the elderly because they may be more sensitive to the effects of the
drug. This medication should be used only when clearly needed during pregnancy. Discuss the risks
and benefits with your doctor. Using this drug during the last 6 months of pregnancy is not
recommended. This drug may pass into breast milk. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: Tell your doctor of all prescription and nonprescription medication you may
use, especially: "blood thinners" (e.g., warfarin), other medications for arthritis (e.g., aspirin,
methotrexate), "water pills" (diuretics), lithium, anti- ulcer medication (e.g., cimetidine), high blood
pressure medication such as ACE inhibitors (e.g., captopril, lisinopril), and beta-blockers (e.g.,
metoprolol, propranolol), probenecid, phenytoin, cyclosporine, sulfa drugs, medicine for diabetes
(e.g., glipizide, glyburide), alendronate. Check the labels on all your medicines because they may
contain aspirin or other aspirin-like NSAIDs (e.g., ibuprofen, naproxen). Ask your pharmacist about
the safe use of those products. Do not start or stop any medicine without doctor or pharmacist
approval
OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room
immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian
residents should call their local poison control center directly. Symptoms of overdose may include
severe stomach pain, coffee ground-like vomit, dark stool, ringing in the ears, change in amount of
urine, unusually fast or slow heartbeat, muscle weakness, slow or shallow breathing, confusion,
severe headache or loss of consciousness.

NOTES: Do not share this medication with others. Laboratory and/or medical tests may be
performed to monitor your progress.

MISSED DOSE: If you miss a dose, use it as soon as you remember. If it is near the time of the next
dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch
up.

STORAGE: Store at room temperature between 36 and 86 degrees F (2 to 30 degrees C) away from
light and moisture

Featured: Nonsteroidal Antiinflammatory Drugs (NSAIDs) Main Article


Nonsteroidal antiinflammatory drugs (NSAIDs) are a class of drugs are used to treat inflammation,
mild to moderate pain, and fever. Examples of the most common NSAIDs include: aspirin salsalate
(Amigesic), diflunisal (Dolobid), ibuprofen (Motrin), ketoprofen (Orudis), nabumetone (Relafen),
piroxicam (Feldene), naproxen (Aleve, Naprosyn,) diclofenac (Voltaren), indomethacin (Indocin),
sulindac (Clinoril), tolmetin (Tolectin), etodolac (Lodine), ketorolac (Toradol), oxaprozin (Daypro),
celecoxib (Celebrex

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