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Complications In Pregnancy

 

Pre-eclampsia, eclampsia or toxemia of pregnancy
Definition:
Pre-eclampsia or preeclampsia (PE) is a disorder of pregnancy characterized by high blood pressure and a large amount of protein in the urine. The disorder usually occurs in the third trimester of pregnancy and gets worse over time. In severe disease there may be red blood cell breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. PE increases the risk of poor outcomes for both the mother and the baby. If left untreated, it may result in seizures at which point it is known as eclampsia.

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Toxemia of pregnancy is a severe condition that sometimes occurs in the latter weeks of pregnancy. It is characterized by high blood pressure; swelling of the hands, feet, and face; and an excessive amount of protein in the urine. If the condition is allowed to worsen, the mother may experience convulsions and coma, and the baby may be stillborn.
The term toxemia is actually a misnomer from the days when it was thought that the condition was caused by toxic (poisonous) substances in the blood. The illness is more accurately called preeclampsia before the convulsive stage and eclampsia afterward.

Preeclampsia affects between 2–8% of pregnancies worldwide. Hypertensive disorders of pregnancy are one of the most common causes of death due to pregnancy. They resulted in 29,000 deaths in 2013 – down from 37,000 deaths in 1990. Preeclampsia usually occurs after 32 weeks; however, if it occurs earlier it is associated with worse outcomes. Women who have had PE are at increased risk of heart disease later in life. The word eclampsia is from the Greek term for lightning. The first known description of the condition was by Hippocrates in the 5th century BCE

Symptoms:
Swelling (especially in the hands and face) was originally considered an important sign for a diagnosis of preeclampsia. However, because swelling is a common occurrence in pregnancy, its utility as a distinguishing factor in preeclampsia is not great. Pitting edema (unusual swelling, particularly of the hands, feet, or face, notable by leaving an indentation when pressed on) can be significant, and should be reported to a health care provider.

In general, none of the signs of preeclampsia are specific, and even convulsions in pregnancy are more likely to have causes other than eclampsia in modern practice. Further, a symptom such as epigastric pain may be misinterpreted as heartburn. Diagnosis, therefore, depends on finding a coincidence of several preeclamptic features, the final proof being their regression after delivery.

The symptoms of toxemia of pregnancy (which may lead to death if not treated) are divided into three stages, each progressively more serious:
Mild preeclampsia symptoms include edema (puffiness under the skin due to fluid accumulation in the body tissues, often noted around the ankles), mild elevation of blood pressure, and the presence of small amounts of protein in the urine.

Severe preeclampsia symptoms include extreme edema, extreme elevation of blood pressure, the presence of large amounts of protein in the urine, headache, dizziness, double vision, nausea, vomiting, and severe pain in the right upper portion of the abdomen.
Eclampsia symptoms include convulsions and coma.

Risk Factors:
Known risk factors for preeclampsia include:

*Nulliparity (never given birth)
*Older age, and diabetes mellitus
*Kidney disease
*Chronic hypertension
*Prior history of preeclampsia
*Family history of preeclampsia
*Advanced maternal age (>35 years)
*Obesity
*Antiphospholipid antibody syndrome
*Multiple gestation
*Having donated a kidney.
*Having sub-clinical hypothyroidism or thyroid antibodies

It is also more frequent in a women’s first pregnancy and if she is carrying twins. The underlying mechanism involves abnormal formation of blood vessels in the placenta amongst other factors. Most cases are diagnosed before delivery. Rarely, preeclampsia may begin in the period after delivery. While historically both high blood pressure and protein in the urine were required to make the diagnosis, some definitions also include those with hypertension and any associated organ dysfunction. Blood pressure is defined as high when it is greater than 140 mmHg systolic or 90 mmHg diastolic at two separate times, more than four hours apart in a women after twenty weeks of pregnancy. PE is routinely screened for during prenatal care.
Causes:
There is no definitive known cause of preeclampsia, though it is likely related to a number of factors. Some of these factors include:

*Abnormal placentation (formation and development of the placenta)
*Immunologic factors
*Prior or existing maternal pathology – preeclampsia is seen more at a higher incidence in individuals with preexisting hypertension, obesity, antiphospholipid antibody syndrome, and those with history of preeclampsia
*Dietary factors, e.g. calcium supplementation in areas where dietary calcium intake is low has been shown to reduce the risk of preeclampsia.
*Environmental factors, e.g. air pollution
*Those with long term high blood pressure have a risk 7 to 8 times higher than those without.

Physiologically, research has linked preeclampsia to the following physiologic changes: alterations in the interaction between the maternal immune response and the placenta, placental injury, endothelial cell injury, altered vascular reactivity, oxidative stress, imbalance among vasoactive substances, decreased intravascular volume, and disseminated intravascular coagulation.

While the exact cause of preeclampsia remains unclear, there is strong evidence that a major cause predisposing a susceptible woman to preeclampsia is an abnormally implanted placenta. This abnormally implanted placenta is thought to result in poor uterine and placental perfusion, yielding a state of hypoxia and increased oxidative stress and the release of anti-angiogenic proteins into the maternal plasma along with inflammatory mediators. A major consequence of this sequence of events is generalized endothelial dysfunction. The abnormal implantation is thought to stem from the maternal immune system’s response to the placenta and refers to evidence suggesting a lack of established immunological tolerance in pregnancy. Endothelial dysfunction results in hypertension and many of the other symptoms and complications associated with preclampsia.

One theory proposes that certain dietary deficiencies may be the cause of some cases. Also, there is the possibility that some forms of preeclampsia and eclampsia are the result of deficiency of blood flow in the uterus.

Diagnosis:
Pre-eclampsia is diagnosed when a pregnant woman develops:

*Blood pressure >_ 140 mm Hg systolic or  >_  90 mm Hg diastolic on two separate readings taken at least four to six hours apart after 20 weeks gestation in an individual with previously normal blood pressure.
*In a woman with essential hypertension beginning before 20 weeks gestational age, the diagnostic criteria are: an increase in systolic blood pressure (SBP) of   >_ 30mmHg or an increase in diastolic blood pressure (DBP) of   >_15mmHg.
*Proteinuria  >_ 0.3 grams (300 mg) or more of protein in a 24-hour urine sample or a SPOT urinary protein to creatinine ratio  >_ 0.3 or a urine dipstick reading of 1+ or greater (dipstick reading should only be used if other quantitative methods are not available)

Suspicion for preeclampsia should be maintained in any pregnancy complicated by elevated blood pressure, even in the absence of proteinuria. Ten percent of individuals with other signs and symptoms of preeclampsia and 20% of individuals diagnosed with eclampsia show no evidence of proteinuria. In the absence of proteinuria, the presence of new-onset hypertension (elevated blood pressure) and the new onset of one or more of the following is suggestive of the diagnosis of preeclampsia:

*Evidence of kidney dysfunction (oliguria, elevated creatinine levels)
*Impaired liver function (impaired liver function tests)
*Thrombocytopenia (platelet count <100,000/microliter)
*Pulmonary edema
*Ankle edema pitting type
*Cerebral or visual disturbances
*Preeclampsia is a progressive disorder and these signs of organ dysfunction are indicative of severe preeclampsia. A systolic blood pressure ?160 or diastolic blood pressure ?110 and/or proteinuria >5g in a 24-hour period is also indicative of severe preeclampsia. Clinically, individuals with severe preeclampsia may also present epigastric/right upper quadrant abdominal pain, headaches, and vomiting. Severe preeclampsia is a significant risk factor for intrauterine fetal death.

Of note, a rise in baseline blood pressure (BP) of 30 mmHg systolic or 15 mmHg diastolic, while not meeting the absolute criteria of 140/90, is still considered important to note, but is not considered diagnostic.

Predictive tests:
There have been many assessments of tests aimed at predicting preeclampsia, though no single biomarker is likely to be sufficiently predictive of the disorder. Predictive tests that have been assessed include those related to placental perfusion, vascular resistance, kidney dysfunction, endothelial dysfunction, and oxidative stress. Examples of notable tests include:

*Doppler ultrasonography of the uterine arteries to investigate for signs of inadequate placental perfusion. This test has a high negative predictive value among those individuals with a history of prior preeclampsia.
*Elevations in serum uric acid (hyperuricemia) is used by some to “define” preeclampsia,[14] though it has been found to be a poor predictor of the disorder. Elevated levels in the blood (hyperuricemia) are likely due to reduced uric acid clearance secondary to impaired kidney function.
*Angiogenic proteins such as vascular endothelial growth factor (VEGF) and placental growth factor (PIGF) and anti-angiogenic proteins such as soluble fms-like tyrosine kinase-1 (sFlt-1) have shown promise for potential clinical use in diagnosing preeclampsia, though evidence is sufficient to recommend a clinical use for these markers.
*Recent studies have shown that looking for podocytes, specialized cells of the kidney, in the urine has the potential to aid in the prediction of preeclampsia. Studies have demonstrated that finding podocytes in the urine may serve as an early marker of and diagnostic test for preeclampsia. Research is ongoing.

Differential diagnosis:
Pre-eclampsia can mimic and be confused with many other diseases, including chronic hypertension, chronic renal disease, primary seizure disorders, gallbladder and pancreatic disease, immune or thrombotic thrombocytopenic purpura, antiphospholipid syndrome and hemolytic-uremic syndrome. It must be considered a possibility in any pregnant woman beyond 20 weeks of gestation. It is particularly difficult to diagnose when preexisting disease such as hypertension is present. Women with acute fatty liver of pregnancy may also present with elevated blood pressure and protein in the urine, but differs by the extent of liver damage. Other disorders that can cause high blood pressure include thyrotoxicosis, pheochromocytoma, and drug misuse
Treatment:
Preeclampsia and eclampsia cannot be completely cured until the pregnancy is over. Until that time, treatment includes the control of high blood pressure and the intravenous administration of drugs to prevent convulsions. Drugs may also be given to stimulate the production of urine. In some severe cases, early delivery of the baby is needed to ensure the survival of the mother.

Prevention:
Recommendations for prevention include: aspirin in those at high risk, calcium supplementation in areas with low intake, and treatment of prior hypertension with medications. In those with PE delivery of the fetus and placenta is an effective treatment. When delivery becomes recommended depends on how severe the PE and how far along in pregnancy a person is. Blood pressure medication, such as labetalol and methyldopa, may be used to improve the mother’s condition before delivery. Magnesium sulfate may be used to prevent eclampsia in those with severe disease. Bedrest and salt intake have not been found to be useful for either treatment or prevention.

Diet:
Protein or calorie supplementation have no effect on preeclampsia rates, and dietary protein restriction does not appear to increase preeclampsia rates. Further, there is no evidence that changing salt intake has an effect.

Supplementation with antioxidants such as vitamin C and E has no effect on preeclampsia incidence, nor does supplementation with vitamin D. Therefore, supplementation with vitamins C, E, and D is not recommended for reducing the risk of pre-eclampsia.

Calcium supplementation of at least 1 gram per day is recommended during pregnancy as it prevents preeclampsia where dietary calcium intake is low, especially for those at high risk. Low selenium status is associated with higher incidence of preeclampsia.

Aspirin:
Taking aspirin is associated with a 1% to 5% reduction in preeclampsia and a 1% to 5% reduction in premature births in women at high risk. The WHO recommends low-dose aspirin for the prevention of preeclampsia in women at high risk and recommend it be started before 20 weeks of pregnancy. The United States Preventive Services Task Force recommends a low-dose regimen for women at high risk beginning in the 12th week.

Physical activity:
There is insufficient evidence to recommend either exercise or strict bedrest as preventative measures of pre-eclampsia.

Smoking cessation:
In low-risk pregnancies the association between cigarette smoking and a reduced risk of preeclampsia has been consistent and reproducible across epidemiologic studies. High-risk pregnancies (those with pregestational diabetes, chronic hypertension, history of preeclampsia in a previous pregnancy, or multifetal gestation) showed no significant protective effect. The reason for this discrepancy is not definitively known; research supports speculation that the underlying pathology increases the risk of preeclampsia to such a degree that any measurable reduction of risk due to smoking is masked. However, the damaging effects of smoking on overall health and pregnancy outcomes outweighs the benefits in decreasing the incidence of preeclampsia. It is recommended that smoking be stopped prior to, during and after pregnancy

Restriction of salt in the diet may help reduce swelling, it does not prevent the onset of high blood pressure or the appearance of protein in the urine. During prenatal visits, the doctor routinely checks the woman’s weight, blood pressure, and urine. If toxemia is detected early, complications may be reduced.

Resources:
http://health.howstuffworks.com/pregnancy-and-parenting/pregnancy/complications/a-guide-to-pregnancy-complications-ga13.htm
http://en.wikipedia.org/wiki/Pre-eclampsia

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Endometrial Biopsy

Introduction:An endometrial biopsy is a way for your doctor to take a small sample of the lining of the uterus (endometrium). The sample is looked at under a microscope for abnormal cells. An endometrial biopsy helps your doctor find any problems in the endometrium. It also lets your doctor check to see if your body’s hormone levels that affect the endometrium are in balance.

Doctors take biopsies of areas that look abnormal and use them to detect cancer, precancerous cells, infections, and other conditions. For some biopsies, the doctor inserts a needle into the skin and draws out a sample; in other cases, tissue is removed during a surgical procedure.

The lining of the uterus changes throughout a woman’s menstrual cycle. Early in the menstrual cycle, the lining grows thicker until a mature egg is released from an ovary (ovulation). If the egg is not fertilized by a sperm, the lining is shed during normal menstrual bleeding.

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There are several ways to do an endometrial biopsy. Your doctor may use:

*A soft, straw-like device (pipelle) to suction a small sample of lining from the uterus. This method is fast and is not very painful.

*A sharp-edged tool called a curette. Your doctor will scrape a small sample and collect it with a syringe or suction. This is called a dilation and curettage (D&C). A D&C may be done to control heavy uterine bleeding (hemorrhage) or to help find the cause of bleeding. This is done with general or regional anesthesia.

*An electronic suction device (Vabra aspiration). This method can be uncomfortable.

*A spray of liquid (jet irrigation) to wash off some of the tissue that lines the uterus. A brush may be used to remove some of the lining before the washing is done.

When a woman is having a hard time becoming pregnant, an endometrial biopsy may be done to see whether the lining of her uterus can support a pregnancy.

An endometrial biopsy may also be done to find the cause of abnormal uterine bleeding, to check for overgrowth of the lining (endometrial hyperplasia), or to check for cancer.

An endometrial biopsy is sometimes done at the same time as another test, called hysteroscopy, which allows your doctor to look through a small lighted tube at the lining of the uterus.

Why It Is Done
An endometrial biopsy is done to:

*Check for cancer. For example, an endometrial biopsy may be done to help determine the cause of some abnormal Pap test results.
*Find the cause of heavy, prolonged, or irregular uterine bleeding. It is often done to find the cause of uterine bleeding in women who have gone through menopause.

*See whether the lining of the uterus (endometrium) is going through the normal menstrual cycle changes.

How To Prepare
Tell your doctor if you:

*Are or might be pregnant. An endometrial biopsy is not done during pregnancy.

*Are taking any medicines.

*Are allergic to any medicines.

*Have had bleeding problems or take blood-thinners, such as aspirin or warfarin (Coumadin).

*Have been treated for a vaginal, cervical, or pelvic infection.

*Have any heart or lung problems.
Do not douche, use tampons, or use vaginal medicines for 24 hours before the biopsy. You will empty your bladder just before your biopsy.

If you are not bleeding heavily, you might want to take an NSAID medicine such as ibuprofen one to two hours before the test, to reduce the possibility of uterine cramps during the procedure. Ask your physician for a recommendation ahead of time.

You will need to sign a consent form that says you understand the risks of an endometrial biopsy and agree to have the test done. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results may mean. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?) .

If you are having a dilation and curettage (D&C) and will go to sleep (general anesthesia) for the test, do not eat or drink anything for 8 hours before the test. If you are taking any medicines, ask your doctor what medicines you can take the day of the test.

How It Is Done
An endometrial biopsy is usually done by a gynecologist, a family medicine physician, or a nurse practitioner who has been trained to do the test. The sample will be looked at by a pathologist. The biopsy can be done in your doctor’s office.

Your cervix may be numbed with a spray or injection of local anesthetic.

You will need to take off your clothes below the waist. You will be given a covering to drape around your waist. You will then lie on your back on an examination table with your feet raised and supported by foot rests (stirrups).

Your doctor will put an instrument with smooth, curved blades (speculum) into your vagina. The speculum gently spreads apart the vaginal walls so your doctor can see inside the vagina and the cervix. See a picture of a pelvic examination with a speculum. The cervix is washed with a special solution and may be grasped and held in place with a clamp called a tenaculum.

The tool to collect the sample is guided through the cervix into the uterus. The tool may be moved up and down to collect the sample. Most women have some cramping during the biopsy.

An endometrial biopsy takes 5 to 15 minutes.

Dilation and curettage (D&C)
A D&C is usually done in a hospital or clinic. Most women do not need to stay overnight but can go home the same day.

Your doctor will put an instrument with smooth, curved blades (speculum) into your vagina. The speculum gently spreads apart the vaginal walls so your doctor can see inside the vagina and the cervix. Your cervix will be gently spread open (dilated). Depending on the reason for the D&C, your doctor may use a tool called a hysteroscope to look inside the uterus. A small spoon-shaped instrument (curette) is then guided through the cervix and into the uterus. The top layer of the lining of the uterus is carefully scraped off and removed (along with any other tissue that looks abnormal) for biopsy.

If you have general anesthesia, you will be watched by a nurse in the recovery room until you are fully awake.

You can do most of your normal activities in a few days. Do not lift anything heavy for a few days after the test. Do not douche or have sex for one week after the test.

How It Feels
If you have not had any pain medicine, you may feel a sharp cramp as the tool is guided through your cervix. You may feel more cramping when the biopsy sample is collected. Most women find that the cramping feels like a really bad menstrual cramp.

Some women feel dizzy and sick to their stomachs. This is called a vasovagal reaction. This feeling will go away after the biopsy.

An endometrial biopsy usually causes some vaginal bleeding. You can use a pad for the bleeding or spotting.

Dilation and curettage (D&C)
If general anesthesia is used during a D&C, you will be asleep and feel nothing. After the test, you will feel sleepy for a few hours. You may be tired for a few days after the test. You may also have a mild sore throat if a tube (endotracheal tube, or ET) was placed in your throat to help you breathe during the test. Using throat lozenges and gargling with warm salt water may help relieve your sore throat.

Risks Factors:
You might have pelvic cramps (sometimes intense) during the procedure and sometimes for a day or two afterward; you may also experience a small amount of vaginal bleeding. It is extremely rare to have heavy bleeding or to develop an infection that needs treatment.There is also a small risk of disturbing a very early pregnancy. To guard against this, your doctor might order a pregnancy test before performing the biopsy.

After the test:
You may feel some soreness in your vagina for a day or two. Some vaginal bleeding or discharge is normal for up to a week after a biopsy. You can use a sanitary pad for the bleeding. Do not do strenuous exercise or heavy lifting for one day after your biopsy. Do not douche. You may have to avoid sex or using tampons for several days. Ask your doctor when you can have sex or use tampons again.

Follow any instructions your doctor gave you. Call your doctor if you have:

*Heavy vaginal bleeding (more than a normal menstrual period).

*A fever.

*Belly pain.

*Bad-smelling vaginal discharge.

Results:
Time to know the results:
An endometrial biopsy is a way for your doctor to take a small sample of the lining of the uterus (endometrium). Lab results from a biopsy may take several days to get back.


Endometrial biopsy  Normal
: No abnormal cells or cancer is found. For women who have menstrual cycles, the lining of the uterus is at the right stage for the time in the menstrual cycle when the biopsy was done.

Endometrial biopsy  Abnormal:

*A noncancerous (benign) growth, called a polyp, is present.

*Overgrowth of the lining of the uterus (endometrial hyperplasia) is present.

*Cell changes that may lead to cancer are present.

For women who have menstrual cycles, the lining of the uterus is not at the right stage for the time in the menstrual cycle when the biopsy was done. More tests may be needed.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/endometrial-biopsy.shtml
http://women.webmd.com/endometrial-biopsy

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Hepatitis

Knowing the ABCs of this liver disorder can save your life. Though some hepatitis viruses cause an acute but temporary flulike illness, others can produce a chronic, festering liver infection. Natural therapies are designed to protect the liver and boost your immune system.
Symptoms:-

Fatigue.
Fever.
Loss of appetite.
Nausea and vomiting.
Aching muscles or joints.
Abdominal discomfort, pain, or swelling.
Jaundice (yellowish tinge of skin and whites of eyes).
Dark urine and pale stools.

When to Call Your Doctor :
If you think you have been exposed to hepatitis, either through contaminated food or water or by sexual contact with an infected person.
If you develop lingering flulike symptoms. During its acute phase, viral hepatitis so closely resembles the flu that it is frequently misdiagnosed.
If you develop jaundice or other symptoms of hepatitis.
Reminder: If you have a medical condition, talk to your doctor before taking supplements.

What It Is :
Hepatitis is an inflammation of the liver. Of the two forms — acute and chronic — the first is the easier to treat. Hepatitis can be caused by any of six viruses, called A, B, C, D, E, and G. Hepatitis A, the most common, is highly contagious; it produces acute flulike symptoms but usually no long-lasting damage. Hepatitis B and C, on the other hand, can linger for years, often causing few or no symptoms but in some cases leading to irreversible liver scarring (cirrhosis) or liver cancer. Types D, E, and G are rare. All forms of hepatitis attack the liver, impairing its ability to process sugars and carbohydrates, to secrete fat-digesting bile, and to rid the body of toxins and waste. But the chronic forms are the most dangerous because they may ultimately lead to liver failure.

What Causes It:
Whether contracted through contaminated food or water (type A), or through blood transfusions, infected hypodermic needles, or sexual intercourse (types B and C), hepatitis is most often caused by a viral infection. Certain medications, toxic chemicals, or years of alcohol abuse can also result in hepatitis. Rarely, an autoimmune dysfunction — in which the immune system attacks the body’s own tissues — is to blame. And sometimes, no cause can be determined.

How Supplements Can Help :
Conventional medicines have achieved only limited success in treating hepatitis, particularly the more dangerous chronic form. The natural therapies listed in the chart are designed to protect and strengthen the liver and boost general immunity. They should be used together, along with conventional drugs, until symptoms of acute hepatitis subside. Benefits may be noticed within a week. For chronic disease, take them long term.

What Else You Can Do :
Watch what you eat and drink when traveling in areas where sanitation is poor and disease rates high. Have only bottled water and cooked foods.
Refrain from alcohol, especially during and for a month after an acute illness, or until your doctor says your liver function tests are normal.
Make sure disposable or sterilized needles are used during acupuncture, body piercing, tattooing, and similar procedures.
Vaccines against both hepatitis A and hepatitis B are available. Ask your doctor if you should have one or both.

Supplement Recommendations:-

Vitamin C
Vitamin E
Milk Thistle
Licorice
Lipotropic Combination
Alpha-lipoic Acid
Dandelion Root

Vitamin C
Dosage: 1,000 mg 3 times a day.
Comments: Reduce dose if diarrhea develops.

Vitamin E
Dosage: 400 IU a day.
Comments: Check with your doctor if taking anticoagulant drugs.

Milk Thistle
Dosage: 150 mg 3 times a day.
Comments: Standardized to contain at least 70% silymarin.

Licorice
Dosage: 200 mg 3 times a day for a maximum of 10 days.
Comments: Standardized to contain 22% glycyrrhizin or glycyrrhizinic acid; can raise blood pressure. Don’t use DGL form.

Lipotropic Combination
Dosage: 2 pills twice a day.
Comments: Should contain milk thistle, choline, inositol, and other ingredients.

Alpha-lipoic Acid
Dosage: 200 mg 3 times a day.
Comments: Can be taken with or without food.

Dandelion Root
Dosage: 500 mg standardized extract twice a day.
Comments: May be contained in lipotropic combination formulas.
Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Source:Your Guide to Vitamins, Minerals, and Herbs (Reader’s Digest)