This case report discusses a 29-year-old woman with known epilepsy who was referred at 32 weeks and 3 days of her twin pregnancy due to severe preeclampsia. She had a history of epilepsy for 10 years and was nonadherent to medication. During her hospital stay, she developed one witnessed seizure and was diagnosed with eclampsia. She underwent an emergency c-section at 34 weeks and 5 days, delivering twins. Her hospital course was otherwise uncomplicated, and she was discharged on antiepileptic medications with plans for psychiatric follow-up to improve medication adherence.
Case presentation on mengoencephalitis |Inflammation of the brain NEHA MALIK
Inflammation of the brain and surrounding tissues, usually caused by infection.
Meningoencephalitis is a condition that's usually caused by a virus, bacterium, parasite or other microorganism. Examples include West Nile virus, mumps or tuberculosis.
Symptoms vary, depending on the cause. They may include fever, confusion, vomiting, seizures or, if left untreated, death.
Treatment may include antibiotics, antivirals or supportive care, depending on the origin of the disease.
Case presentation on mengoencephalitis |Inflammation of the brain NEHA MALIK
Inflammation of the brain and surrounding tissues, usually caused by infection.
Meningoencephalitis is a condition that's usually caused by a virus, bacterium, parasite or other microorganism. Examples include West Nile virus, mumps or tuberculosis.
Symptoms vary, depending on the cause. They may include fever, confusion, vomiting, seizures or, if left untreated, death.
Treatment may include antibiotics, antivirals or supportive care, depending on the origin of the disease.
It is a case study report of mucopolysaccharidosis, I did when I was posted in Kanti Children's hospital
Prepared by:
Rashmi Regmi
B. Sc Nursing
Manmohan Memorial Institute of Health Sciences
Case Study on Intrauterine Growth RestrictionAbhineet Dey
A clinically based study of a case of Intrauterine Growth Restriction (IUGR) or Foetal Growth Restriction (FGR).
Moderator:
Dr M. K. Mazumdar
Asst. Professor,
Dept. of Obstetrics and Gynaecology,
Gauhati Medical College & Hospital
Presented by:
29: Abhineet Dey
30: Devasree Kalita
31: Parishmita Sharma
33: Ankur Jain
34: Dhurjyoti Nath
35: Mousumi Mehtaz
42: Liza Hazarika
Students of 8th Semester,
Gauhati Medical College & Hospital, Guwahati, Assam
It is a case study report of mucopolysaccharidosis, I did when I was posted in Kanti Children's hospital
Prepared by:
Rashmi Regmi
B. Sc Nursing
Manmohan Memorial Institute of Health Sciences
Case Study on Intrauterine Growth RestrictionAbhineet Dey
A clinically based study of a case of Intrauterine Growth Restriction (IUGR) or Foetal Growth Restriction (FGR).
Moderator:
Dr M. K. Mazumdar
Asst. Professor,
Dept. of Obstetrics and Gynaecology,
Gauhati Medical College & Hospital
Presented by:
29: Abhineet Dey
30: Devasree Kalita
31: Parishmita Sharma
33: Ankur Jain
34: Dhurjyoti Nath
35: Mousumi Mehtaz
42: Liza Hazarika
Students of 8th Semester,
Gauhati Medical College & Hospital, Guwahati, Assam
A Case of Primigravida with 36 weeks of pregnancy with IUD with obstructed la...Faisal Abdullah
This case was presented on weekly seminar of Department of Gynaecology and Obstetrics ( Unit 1) of Faridpur Medical College Hospital, in October 2019, by Intern Doctor Dr. Faisal Abdullah.
OBSTRUCTED LABOR is an emergency that poses significant risk to the life of both mother and fetus. A condition usually associated with low socioeconomic status puts much burden on the fragile health care delivery in subsaharan Africa
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
3. objective
• To discuss about evaluation and management eclampsia on epilepsy
by Zerihun W. 3
4. Identification
• Name …. T . T
• Age …….. 29
• Sex ……… F
• MRN ……1026864
• DOA …….13/12/13 E.C
• DOD …….01/13/13 E.C
by Zerihun W. 4
5. Referral On 12/12/13
• She refered from K/H/C as a case of epilepsy + Twin pregnancy
• This is 29 yrs. old GII PI(Alive by VD) whose GA was 32W3D from
early ultrasound. She had regular ANC
PE
V/S BP 110/70
Baseline investigation
VDRL
PICT Negative
HBSAg
BG O+ve
Reason for referral
For better management
by Zerihun W. 5
6. Duty R2 EVALUATION @ 12;30 PM 13/12/13
• This is 29 years old GII PI(alive by VD) whose clamed Amenorrhea for the
past 08 month GA form 22w5d ultrasound 32w4d. She had regular ANC
follow up at local HC where routine care given.
• She was referred as a case Twin + epilepsy and linked from regular ANC
with sever record of BP
• She is a know epileptic patient for the last 10 years started after delivery of
first baby. She had repeated attack of abnormal body movement which
involved all extremity with up roving of the eye & drooling of saliva
followed by loss of conscious of unknown duration.
• Before the attack she experience shortness of breath.
by Zerihun W. 6
7. • For this compliant She wanted to holy water for the first 06 years. Then
because of the repeated attack she was visit to HC and start unspecified
medication for about 02 years and discontinued because drug was not
available at HC and unafforded to buy outside.
• The pregnancy was followed at HC since 5 month this pregnancy. Until 8
month she had not attach through out the pregnancy. The first attack in this
px at home involved all extremity followed by loss of conscious, it was 5
day before arrival to our hospital
• Otherwise
She didn’t have fever, pushing down pain, leakage of liquor
She didn’t have known chronic illness in her family as well as herself
such as chronic hypertension, cardiac and family history
Previous pregnancy was uneventful
by Zerihun W. 7
8. P/E
• GA :- well looking
• V/S :- Bp :- 155113 PR:- 88 RR:- 20 T:- ATT
• HEENT :- Pink conjunctiva & NIS
• LG :- No Palpable LN
• CHEST :- Clear & Resonance
• CVS :- S1 & S2 Well heard, No M or G
• ABD :- term size gravid uterus
multiple fetal part palpable
FHR both twin normal
by Zerihun W. 8
9. • GUS :- no vaginal bleeding or leakage of liquor
• MUK :- No Edema
• CNS :- COTPP
9
10. Ass,t
pp
Early preterm px
Twin px (?MCDA)
Known Epilepsy (not on medication)
PE w SF (raised BP)
Plan
Do CBC, ECG, OFT, Bilirubin
Target scan
To consult medical side
Stabilized with mgso4 and start methyldopa 500 mg po TID
Dexamethasone started
Initiate antiepileptic after consultation
Consult R3
by Zerihun W. 10
normal
11. R3 evaluation 13/12/13
• HX and PE revised and the same
• Obstetric ultrasound done by Y3
Twin px
TA EFW 1.7 RBPP
TB EFW 1.5 RBPP
Single placenta
Intertwin membrane 1.8cm
Fetal sex the same
N Doppler
• Plan
Start anticonvulsant after consult medical side
Continues dexa, methyldopa, mgso4
Follow with preeclampsia chart
Admit to MW(14/12/13)
by Zerihun W. 11
12. • HX and PE revised and the same
She had one episode of abnormal body movement witnessed in EOPD
lasting than 1 mint
• Ass the same
• Plan
Phenytoin load with 1g po the 100 mg po TID
Continues obs follow-up
Consult neurologic side
Consult psychiatric side
by Zerihun W. 12
Medical side evaluation on 13/12/13
13. Psychiatry evaluation 13/12/13
• Hx Revised and the same
She has no loss of interest, or mood change
She had no hx elevated mood, irritability or increase energy
She has no hx of suspiciousness, hearing voice or seeing other can't see
She has no aggressive behavior of disorganized behavior
She has no hx of suicidal attempt pt. self harm
She has no hx of excessive wariness or fear
She has no hx of head injury or family hx of seizures
• Ass the same
• Plan
Need frequent psychiatric screening
No current mental health disorder
Consult medical side and neurology
by Zerihun W. 13
14. R2 evaluation MW
• Hx & Px Revised and the same
• Ass
PP
Early preterm px
Twin px (MCDA)
Known Epilepsy
PE w SF (raised BP)
Selective IUGR of TB
• Target scan
TA 2 kg TB 1.3 kg discrepancy 35 %
MCDA
Doppler N
by Zerihun W. 14
15. • Plan
Update CBC, OFT 2x weekly
Continue Phenytoin 100 mg po TID
Continue methyldopa 500 mg po TID
Dexa,, mgso4 :- completed
Follow with preeclampsia chart
Lung maturity test at 36 week
by Zerihun W. 15
16. R3 decision note 26/12/13 @ 4 pm
• This is 29 yrs. old Gll Pl whose GA 34w5d from 22w6d us kept MW for 02 wk.
with Ass of
PP
Early preterm px
Twin px (MCDA)
Known Epilepsy
PE w SF (raised BP)
Selective IUGR of TB
• She develop one episode of abnormal body movement involving the whole
extremity lasting less than 1 min and loss of consciousness which was
immediately regained. associated with this She has up roving of the eye.
Witnessed by health professional
• Otherwise
She had droving of saliva
She had no headache, blurred vision
She had no nausea epigastric pain vomiting, change in mentation
by Zerihun W. 16
17. P/E
• GA :- ASL RBS 120
• V/S :- Bp :- 13090 PR:- 100 RR:- 20 T:- 36.9 spo2 96 and support w INo2
• HEENT :- Pink conjunctiva & NIS
• LG :- No Palpable LN
• CHEST :- Clear & Resonance
• CVS :- S1 & S2 Well heard, No M or G
• ABD :- term size gravid uterus
multiple fetal part palpable
FHR both twin normal
• GUS :- no vaginal bleeding or leakage of liquor
• MUK :- No Edema
• CNS :- COTPP, GCS 15/15
by Zerihun W. 17
18. • Ass
PP
Early preterm px
Twin px (MCDA)
Known Epilepsy
PE w SF (raised BP)
Selective IUGR of TB
Eclampsia
• Plan
Dexamethasone 6mg IM salvage dose
Load with mgso4
Catheterized
Transfer to LW for Emergency cs
Update CBC, OFT Serum e-
Involve consultant
by Zerihun W. 18
19. 26/12/13
• Emergency caesarean section done with outcome of
TA 1900 gram female alive neonate with APGAR score of 7 & 8
TB 1450 gram female alive neonate with APGAR score of 7 & 8
• IOF
Single placenta with two Dividing mm :- MCDA
by Zerihun W. 19
20. • Post op order
Ampicillin 2g IV QID
Put of MF 500 ml NS/DNS 5%/RL over 24hr
Continue Phenytoin 100mg po TID
Continue Mgso4 maintenance
Keep catheter for at least 12hr
Put on continues VS monitoring
Keep family in her bedside
Watch for vaginal bleeding
Transfer neonates to NICU for evaluation
by Zerihun W. 20
21. NICU evaluation
• Ass
TA :- TA + LBW + AGA + Discordant twin
TA :- TB + LBW + LGA + Discordant twin
• Plan
Send CBC determine BG
Attach baby to the Mather
Start breast feeding
• IVX
B/G B+
HCT TA 41 TB 39%
23% Discordant
by Zerihun W. 21
22. Post op evaluation 27/12/13
• P1 :- 29 yrs. old PII lady on 1st post op day after LUTCS was done for the
indication of Eclampsia + Twin Px with outcome of TA 1900 gram female
alive neonate with APGAR score of 7 & 8 and TB 1450 gram female alive
neonate with APGAR score of 7 & 8. neonate in mother side after
evaluated by pediatric side
• P2 :- Eclampsia
• P3 :- Known epileptic
• S poorly adherent to medication
• Otherwise
She has no headache, blurred vision
She has no abnormal body movement
by Zerihun W. 22
23. P/E
• GA :- well looking
• V/S :- Bp :- 140102 PR:- 80 RR:- 20 T:- 36.1
• HEENT :- Pink conjunctiva & NIS
• LG :- No Palpable LN
• CHEST :- Clear & Resonance
• CVS :- S1 & S2 Well heard, No M or G
• ABD :- 20 wk. sided well contracted uterus
• GUS :- no vaginal bleeding
• MUK :- No Edema
• CNS :- COTPP
by Zerihun W. 23
24. • Ass
smooth post op day
• Plan
Continue phenytoin 100 mg po TID
Nifedipine 10mg po daily
Mgso4 completed
Update CBC, OFT
Follow with PE chart
Advice the mother on drug adherence
Psychiatric side consulted( plan is to link to psychiatric side after discharge
for frequent psychiatric screening)
Folic acid 4 mg po daily
Brain MRI, EEG up on discharge
Next pregnancy follow up should be in hospital and require preconception
care
by Zerihun W. 24
25. INVESTIGATION SUMMERY
by Zerihun W. 25
13/19/13 20/12/13 27/12/13 29/10/20 01/10/20
WBC 4.3X103 4.6X103 6.8X103 7.8X103 6.9X103
HCT 32.8 36 34.6 9.2/25.5 8.5/24.5
PLT 160
u/a -ve
147 179 58 194
OFT Got – 6
Gpt – 13.3
Cr – 0.5
Bun – 15.1
Got – 7.8
Gpt – 13.8
Cr – 0.48
Bun – 18
D bil - <1.16,
T bil - <0.12
Got – 96
Gpt – 84
Cr – 0.58
Bun – 19
D bil – 0.11
T bil - 19
Got – 38
Gpt – 20
Cr – 0.42
Bun – 14
Electrolyte Na+ 138
K+ 4.9
26. U/S SUMMERY
by Zerihun W. 26
13/12/13 15/12/13 18/12/13 22/12/13 25/12/13 26/12/13
TA 1.5kg, SDP
3.8
TB 1.7 kg , SDP
3.8
Mm Thickness
1.8mm
Fetal sex the same
Index
RBPP
N Doppler
?MCDA
TA SDP
3.5CM
TB SDP 4
CM
Thick
dividing mm
Index
RBPP
TA 2kg
TB 1.3 kg
Index
RBPP
N
Doppler
TB
selective
IUGR
MCDA
TA SDP 3
CM
TB SDP
2.1 CM
Index
RBPP
TA SDP 2.7
CM
TB SDP 2.4
CM
Index
RBPP
N doppler
TA SDP 4
CM
TB SDP 3.5
CM
Index
RBPP
N doppler
27. by Zerihun W. 27
Pre OP Follow-up at MW
Post OP Followp-up
28. Summery
• This is 29 yrs. old GII PI lady a known epileptic patient for the last 10 yrs.,
she was took antiepileptic medication for 02 yrs. and discounted 02 yrs.
Back prior to this pregnancy because of finical reason. she had repeated
attack before this pregnancy .
• At GA of 32w3d she was referred as a case of epilepsy from KHC. She was
liked from ANC with sever range BP
• She was admitted PP + Early preterm px + Twin px (MCDA) + Known
Epilepsy + PE w SF (raised BP) + Selective IUGR of TB
• Prior 5 day of referral she has abnormal body movement and 01 episode
witnessed at EOPD, Phenytoin load and on 100 mg po TID
• She stay MW for two weeks. As GA of 34+5 she develop abnormal body
movement of one episode which last less than one minute and considering
eclampsia mgso4 loaded and emergency cs decided with outcome of TA 1.9
kg and TB 1.4 kg
by Zerihun W. 28
31. Eclampsia
• the occurrence of new-onset, generalized, tonic- clonic seizures or coma in
a woman with preeclampsia in the absence of other neurologic condition
• Incidence
GHTN <0.1%
0.6 % PE with out severity feature
2 to 3 PE with severity feature
Developed : 1.5 to 10 cases per 10,000 Deliveries
Developing : 6 to 157 cases per 10,000 Deliveries
by Zerihun W. 31
32. • Risk factor
Nulliparity
Preeclampsia in a previous pregnancy
Age >40 years or <18 years
Family history of preeclampsia
Chronic hypertension
Chronic renal disease
Autoimmune disease (eg, antiphospholipid syndrome, systemic lupus
erythematosus)
Vascular disease
Diabetes mellitus (pregestational and gestational)
Multifetal gestation
Obesity
by Zerihun W. 32
33. Black race
Hydrops fetalis
Woman herself was small for gestational age
Fetal growth restriction, abruptio placentae, or fetal demise in a previous
pregnancy
Prolonged interpregnancy interval if the previous pregnancy was
normotensive; if the previous pregnancy was preeclamptic, a short
interpreg``1nancy interval increases the risk of recurrence
Partner-related factors (new partner, limited sperm exposure
[eg, previous use of barrier contraception])
In vitro fertilization
by Zerihun W. 33
In our case risk Factor for PE
Multiple gestation
Epilepsy
34. • Timing
59 percent -antepartum,
20 percent - intrapartum, and
21 percent -postpartum (90%-with in 1week
by Zerihun W. 34
35. • Supportive of eclampsia
Abnormal body movement typical of eclampsia
PE w SF.
Twin px
• Against eclampsia
She is a know epileptic patient
She had the some attach in this pregnance
Poor adherent to medication
Cerebral symptom absent before and after convulsion
by Zerihun W. 35
In our case
36. Epilepsy
• Seizure is defined as a paroxysmal disorder of the central nervous system
characterized by an abnormal neuronal discharge with or without loss of
consciousness.
• Epilepsy encompasses different syndromes whose cardinal feature is a
predisposition to recurrent unprovoked seizures
Focal Seizures
Generalized Seizures
by Zerihun W. 36
37. • Incidence
Epilepsy affects approximately 1 to 2%
is the most frequent major neurologic complication encountered in
pregnancy.
• Diagnosis
Two unprovoked seizures or
One seizure in a patient with clinical features that make a second seizure
likely
Findings on brain MRI
EEG that are consistent with a diagnosis of
epilepsy
A family history of epilepsy
by Zerihun W. 37
38. • Perinatal morbidity and mortality
increased among women with epilepsy
complications include
preeclampsia,
preterm labor,
bleeding,
placental abruption,
poor fetal growth,
prematurity,
fetal death, and
maternal mortality
by Zerihun W. 38
39. • Risk estimates derived from a population-based cohort study
Maternal death: 80 deaths per 100,000 pregnancies among women with
epilepsy, compared with 6 deaths per 100,000 pregnancies among
women without epilepsy
Cesarean delivery: 41 versus 33 percent
Pregnancy-related hypertension (11 versus 8 percent) and preeclampsia
(7 versus 4 percent)
Antepartum hemorrhage (2.1 versus 1.5 percent)
PPH,(0.7 versus 0.4)
Preterm labor (11 versus 7 percent)
Poor fetal growth (4 versus 2 percent)
Stillbirth (0.8 versus 0.6)
by Zerihun W. 39
In our case
Preeclapmsia
eclampsia
40. • Effect of pregnancy on seizures
For the majority of women with epilepsy (54% to 80%), seizure
frequency will remain similar to their baseline seizure frequency.
Across several studies, seizure frequency increased in 15.8% to 32% of
women and decreased in 3% to 24%.
Seizure free for 9 months prior to pregnancy is associated with an
84% to 92% chance of remaining seizure free during pregnancy.
increased seizure frequency among sleep deprived, stressed or
noncompliant
Labor and delivery are not usually associated with increased
complications.
increased prevalence of comorbid depression and anxiety
by Zerihun W. 40
In our case
She was not on medication
and she multiple seizure
attach so she will have 54 to
80 % risk of seizure
41. • Effect of pregnancy on AED
Altered protein binding,
Delayed gastric emptying,
Nausea and vomiting,
Changes in plasma volume,
Changes in the volume of distribution, and
Even folic acid supplementation can affect the levels of
anticonvulsant medications.
by Zerihun W. 41
42. • Lamotrigine is the most common AED prescribed in pregnancy.
• Given the interindividual variation in AED metabolism and
susceptibility to changes during pregnancy, checking AED drug levels
monthly is recommended for all AEDs.
by Zerihun W. 42
43. • Supportive epilepsy
She is a know epileptic patient
Multiple attach before
Poorly adherent
• Against of epilepsy
PE w SF
by Zerihun W. 43
In our case
44. Epilepsy or Eclampsia: A Diagnostic Dilemma?
• While eclampsia is the serious complication of the preeclampsia specific
for gestational period and epilepsy is a preexisting pathology of pregnancy.
• Both syndrome are characterized by neuroconvulsive syndrome. On the
other hand, epilepsy can be aggravated by the association of preeclampsia
and eclampsia during the pregnancy, both by increasing the number of
convulsive seizures.
• Seizures are diagnosed for the first time during pregnancy, they should
be evaluated as eclampsia until proved otherwise
by Zerihun W. 44
45. • Clinical symptoms helpful in establishing the diagnosis of eclampsia, at
least one of these symptoms in 59% to 75% of the cases
Excessive weight gain
Persistent occipital or frontal headaches 50% to 75%
Blurred vision 19% to 32%
Photophobia,
Epigastric or right upper quadrant pain 19%
Altered mental status.
• 20% to 40% of eclamptic women do not have any premonitory signs or
symptoms before the onset of convulsions.
by Zerihun W. 45
46. • The initial management active seizure in pregnancy should include
maintenance of the airway, oxygenation, and support of adequate perfusion.
• Seizure mgt:
Convulsive seizures be treated promptly with intravenous
benzodiazepines; Lorazepam(0.1-0.2mg/kg) is considered the drug of
choice.
Intravenous phenytoin is also highly effective and has a longer duration
of action.
Mgso4 should be consider if the seizure recurred despite of conventional
anticonvulsant agent
• Monitoring-
Close monitoring for maternal condition and continuous fetal heart rate
monitoring is recommended in the event of a seizure, as well as for a
period of at least an hour after administration of benzodiazepines
by Zerihun W. 46
Literature review in Magnesium sulfate for non-eclamptic status epilepticus
Seizure reduction/control with IV MgSO4 occurred in 14 of the 28 patients
(50.0%), with 2 (7.1%) and 12 (42.9%) displaying partial and complete
responses respectively. Seizures recurred upon withdrawal of MgSO4 therapy
in 50% of the patients whom had reduction/control
Conclusions
Routine use of IV MgSO4 in non-eclamptic SE/RSE cannot be recommended
at this time. Further prospective study of this drug is required in order to
determine its efficacy as an anti-epileptic in this setting.
47. by Zerihun W. 47
Case Report
A 41-year-old pregnant woman Who is a known epilepsy for 15 years and managed with
antiepileptic and PE. At the 34w GA, she had an episode of seizures
• Intravenous diazepam (10 mg), following which seizures subsided.
• After 5 hours, the seizure recurred, and an injection of diazepam (10 mg) and a loading
dose of phenytoin were administered intravenously.
• She again had an episode of seizures. Midazolam given & A loading dose of valproate was
administered over 30 minutes, followed by 400 mg 3 times daily.
• Later A diagnosis of eclampsia and epilepsy was made. An injection of Mgso4 &
emergency cesarean delivery and seizure controlled.
Conclusions
• The initial management administration of a parenteral benzodiazepine, followed by
intravenous phenytoin at conventional doses, is a reasonable approach.
• If the is recurrent generalized tonic-clonic seizures with features suggestive of eclampsia
along with a history of epilepsy then eclampsia with epilepsy should Consider and
termination of pregnancy and Mgso4 treatment require.
48. Intrapartum
• Mode of delivery:
most women have a normal vaginal delivery. elective cesarean section
may be justified in selected cases.
• Epidural analgesia:
Although no evidence exists to support or challenge epidural analgesia
in patients with epilepsy, it is typically utilized to decrease stress and
allow the mother to rest during a long labor.
by Zerihun W. 48
49. postpartum
• Dose adjustment
if the antiseizure drug dose has been altered during pregnancy, a return
to prepregnancy levels should be considered during the first few weeks
after delivery.
Advice on the importance of adequate rest, sleep and compliance with
drug therapy.
Precautions need to be taken to protect the infant if the mother has a
seizure.
by Zerihun W. 49
50. • Breast feeding
All of the antiseizure drugs are measurable in breast milk.
The reported percentage of maternal plasma levels in breast milk varies
from 5 to10% with valproate to 90 percent with ethosuximide.
Most experts believe that taking antiseizure drugs does not generally
contraindicate breast feeding, as probable benefits outweigh risks.
by Zerihun W. 50
51. Twin Px Vs Preeclapmsia, IUGR
• DZ twins arise in about 1% to 1.5% of pregnancies, and MZ twins occur in
0.4% of pregnancies
• There are Certain complications anticipated in the management of labor
and delivery of multiple gestations
Except post Term and macrosomia
by Zerihun W. 51
52. • Maternal complications
GHTN and preeclampsia
Rates of gestational hypertension and preeclampsia were twice as
high in twin compared with singleton pregnancies (13 percent in
twins versus 5 to 6 percent in singletons for both disorders).
Early severe preeclampsia and HELLP syndrome tended to occur
more frequently in multiple gestations.
Other
Gestational diabetes –
Acute fatty liver –
APH, PPH
Manual placenta extraction
iron deficiency anemia,
hyperemesis gravidarum
thromboembolism.
by Zerihun W. 52
53. • Fetal complications
All twins
Growth restriction
Congenital anomalies
Preterm delivery
Monochorionic twins
Selective fetal growth restriction
Single fetal demise of one twin
Twin-twin transfusion syndrome (TTTS) –
Twin anemia-polycythemia sequence (TAPS) –
Twin reversed arterial perfusion sequence (TRAP) –
Monoamniotic twins
Intertwin cord entanglement
Conjoined twins
by Zerihun W. 53
In our case
Maternal and fetal complication of twin px
• Preeclapmsia
• Selected IUGR(there was no poly-oligo
sequence, doppler normal & wight
discrepancy 30% and post natal evaluation
wight discrepancy 21.6%, Hct 41 & 39)
54. Time of termination
• ACOG
Twin Px
Complicated
MCDA with isolated fetal growth restriction termination at 32 to
34 wk.
DCDA with isolated fetal growth restriction termination at 36 to
37 wk.
Uncomplicated MCDA twin is between 34 and 37 6/7 wks.
PE W SF with stable maternal and fetal condition termination at 34 wk.
or at diagnosis if diagnosis later after 34 wk. of GA
by Zerihun W. 54
In our case
lung maturity test planed at 36
wk.
55. Contraception
• LARC such as IUCD will not be affected by enzyme inducing drugs
Can be given to all patients
• OCP, implants, vaginal rings are affected by enzyme inducing AED
Better avoided
• Women taking lamotrigine monotherapy and oestrogen-containing
contraceptives should be informed of the potential increase in seizures due
to a fall in the levels of lamotrigine
by Zerihun W. 55
In our case
She was opted for Implanon and
provided
56. COMMENT
• Referral from HC should be earlier and Feedback should be given
• Documentation and follow up suboptimal
• Termination should be individualized
• Multidepartment involvement in management plan appreciable
• Choice of contraceptive
• Choice of anti epileptic
• Discharge plan good
by Zerihun W. 56
58. REFERENCES
• Williams Obstetrics, 25th Edition
• Gabbe Normal and problem pregnancy, 7th edition
• ACOG. May 2016
• Gabbe 7th Edition
• Uptodate 2018
by Zerihun W. 58
The first visit(13/12/13)
Regular ANC Bp 162/109 the linked to EOPD
10 to 15 percent of women in labor with preeclampsia without severe features will develop signs\symptoms of preeclampsia with severe features
By comparison, smoking decreases the risk of preeclampsia, and Asian and Hispanic women have a lower risk of preeclampsia than white women and a much lower risk than black women
Hypertensive encephalopathy, a possible model for eclampsia
The two conditions share many clinical, radiologic, and pathologic features
Two theories have been proposed to explain these cerebral abnormalities:
Vasospasm: cerebral overregulation and
forced dilation: loss of autoregulation
vasospasm of cerebral arteries, under perfusion of the brain, localized ischemia/infarction, and cytotoxic (intracellular) edema
high systemic pressure (ie, hypertensive encephalopathy) results in hyper perfusion, endothelial damage, and vasogenic (extracellular) edema
-Hypertension is considered the hallmark for the diagnosis of eclampsia. The hypertension can be severe (≥160 mm Hg systolic or ≥110 mm Hg diastolic), as in 20% to 54% of cases, or it can be mild (systolic BP between 140 and 160 mm Hg or diastolic BP between 90 and 110 mm Hg), as in 30% to 60% of cases. However, in 16% of cases, hypertension may be absent. In addition, severe hypertension is more common in patients who develop antepartum eclampsia (58%) and in those who develop eclampsia at 32 weeks’ gestation or later (71%). Moreover, hypertension is absent in only 10% of women who develop eclampsia at or before 32 weeks’ gestation.
-The diagnosis of eclampsia is usually associated with proteinuria (at least 1+ on a dipstick). In a series of 399 women with eclampsia, substantial proteinuria (≥3+ on a dipstick) was present in only 48% of the cases, whereas proteinuria was absent in 14% of the cases. Abnormal weight gain in excess of 2 lb/ wk (with or without clinical edema) during the third trimester might be the first sign before the onset of eclampsia. However, edema was absent in 26% of 399 eclamptic women studied.
-Several clinical symptoms are potentially helpful in establishing the diagnosis of eclampsia. These include persistent occipital or frontal headaches, blurred vision, photophobia, epigastric or right upper quadrant pain, and altered mental status. Women had at least one of these symptoms in 59% to 75% of the cases (Table 31-16). Headaches are reported by 50% to 75% of patients, whereas visual changes are reported in 19% to 32% of patients. These symptoms may occur before or after the onset of convulsions.
-Peripartum seizure is a common manifestation of epilepsy and eclampsia. Epilepsy is a chronic neurologic disorder that may complicate pregnancy, The risk of seizures increases at delivery, with 1% to 2% of women with epilepsy having a seizure during labor or in the first 24 hours postpartum.
-On the other hand, eclampsia is a hypertensive disorder of pregnancy associated with edema, proteinuria, and convulsion. Eclampsia has been reported to be associated with various neurologic problems, such as cerebrovascular accidents and blindness.
-Uncontrolled seizures during pregnancy are dangerous to both the mother and fetus. Tonic-clonic seizures can cause physical injury and abruptio placentae in the mother and hypoxia, acidosis, intracranial hemorrhage, and death in the fetus.4 The pregnant patient may aspirate, causing aspiration pneumonitis during seizure episodes. Fetal bradycardias have been reported during and after maternal convulsions.
-The initial management of patients presenting with active seizure in pregnancy should include maintenance of the airway, oxygenation, and support of adequate perfusion.
Immediate attention must also be applied to the fetus, particularly if it has reached a viable gestational age. While an ongoing evaluation is in progress to investigate the organic causes, administration of a parenteral benzodiazepine, followed by intravenous phenytoin at conventional doses, is a reasonable approach. A computed tomographic (CT) scan of the brain is required to differentiate the central organic cause of seizures from that of eclampsia, but concern for safety of the mother and her
fetus because of radiation exposure remains.5 Our patient had recurrent generalized tonic-clonic seizures with features suggestive of eclampsia along with
a history of epilepsy. We were in a dilemma regarding the pharmacotherapeutic management of seizures in this scenario.
-Our patient responded to conventional antiepileptic agents, but there was recurrence of seizures, which later subsided only after the initiation of magnesium therapy. This implies the generally accepted dictum that if the seizures occur in pregnancy, they should be evaluated as eclampsia until proved otherwise and should be treated as such until the attending physician can perform a proper evaluation. Emergency cesarean delivery is required if there are recurrent generalized seizures, to avoid any maternal and fetal morbidity. Thus, evaluation of the cause of seizures remains a limitation in an emergency scenario.
Women had at least one of these symptoms in 59% to 75% of the cases
anti-epileptic properties from N-methyl D-aspartate (NMDA) receptor inhibition. To date, a few animal models support this concept [3–6]. Clinically, MgSO4 has seen much attention within the obstetrics literature as an effective prophylactic and therapeutic agent for pre-eclampsia and eclampsia, respectively [7]. Furthermore, the lack of significant side effects is appealing due to concerns about fetal toxicity. The efficacy of MgSO4 as an AED in the setting of eclampsia is well documented since the early 1900s, with the mechanism of action attributed to both NMDA receptor antagonism and cerebral vasodilation. In addition, systematic reviews have demonstrated the superiority of MgSO4 over diazepam, phenytoin and lytic cocktails in the setting of eclampsia [8–10]. During status epilepticus (SE) and refractory status epilepticus (RSE) the NMDA receptor plays a key role in pharmaco-resistance and epileptigenicity. As seizures remain uncontrolled, there is an up-regulation of the NMDA receptor, leading to a glutamate mediated excitotoxicity and seizure potentiation [11,12]. This has lead to the interest in NMDA receptor antagonists as AED in the setting of SE/RSE. Ketamine is an example of one such drug which has displayed some efficacy in this setting [13]. The use of MgSO4 in the setting of non-eclamptic SE/RSE has been mentioned in protocols and reviews of therapies [14–16]. To date however there are only a small number of cases describing the use of IV MgSO4 for non-eclamptic SE/RSE [17–37]. Our goal was to perform a systematic review of the literature on the use of IV MgSO4, a NMDA receptor antagonist, for non-eclamptic SE/RSE.
women with frequent seizures during the third trimester or a history of status epilepticus during severe stress.
1. Lamotrigine clearance decreases quickly in the first week postpartum, and dose adjustments should be made sooner. In one case series, postpartum taper schedules of lamotrigine appeared to reduce the likelihood of maternal lamotrigine toxicity. The dose was incrementally reduced at postpartum days 3, 7, and 10, with return to preconception dose or preconception dose plus 50 mg to help counteract the effects of sleep deprivation.