[Aplastic anaemia associated with pregnancy].

Aplastic anaemia is rear disease caused by destruction of pluripotent stem cells in bone marrow. Pregnancy is one of the main factor that lead to immunosuppression. During pregnancy aplastic anaemia could be life-threatening for both mother and child, because of the variety of complications like bleeding and infections. We introduce the first case of pregnant woman with aplastic anaemia in Bulgaria. The woman was diagnosed in 12-13 gestational week. All biometric characteristics of the foetus were normal. The patient was consulted with oncohaematologists, pediatricians, specialists of Obstetrics and Gynaecology, and intensivists. Methylprednisolone, antibiotics, packed cells and platelet transfusions were initiated. However, the moment for interruption of the pregnancy was missed (first trimester). The woman developed a fever and vomited bloody material. Despite the optimal supportive treatment, the patient died. The pathoanatomy diagnose is Aplastic anaemia, induced by the pregnancy. From our experience with that case and other references from the literature we conclude that all pregnant woman with aplastic anaemia should interrupt their pregnancy during first trimester. In those patients who are diagnosed at later terms of pregnancy very supportive infusions and immunosuppressive therapy should be made, including antithymocyte globulin and/or cyclosporine. Women with no improvement from that therapy should achieve a bone-marrow transplantation.

[Unlicensed and off label usage of some drugs in obstetric practice].

Off label usage refer with prescribing of some drugs outside indications licensed by the regulatory organs of the country or is in conflict with the product information. During pregnancy there are cases, when the health of the mother is a priority and the obstetrician has no alternative, except off label using the medication. The examples, which we show, include usage of different drugs in Bulgaria with their unlicensed indications, age group, dosage and duration of the curing course. Unlicensed usage is not illegal, because of necessity to meet the special needs of the patient. Such prescribes can not be accepted as an experiment, if there are based over publications in scientific magazines or/and presented in international congresses and consensuses. That question is covered by EC Pharmaceutical Directive 89/341 EEC.

[Is it already time to legalize the usage of Cytotec (Misoprostol) in the obstetrics' practice?].

UNLABELLED: Cytotec (Misoprostol) is a prostaglandin E1 9(PgE1) analogue. Despite that it is not officially registered for obstetric and gynaecological targets, Cytotec (C) is widely used in this sphere. The author aims to study the effect and results from C application used for delivery (birth) induction, as well as means for cervical maturation. In order to reach this aim, beside the group of 45 pregnant women to who we applied C, we also reviewed the existing literature, which reported proves for C efficacy, pharma-kynetics and the safe aspects of its application (usage) in pregnancy. MATERIAL AND METHODS: C was used with 45 pregnant women, divided in two groups: I group--27 pregnant women with oral application and II group--18 pregnant women with vaginal application. C was given per os in dosage 50 microg at 4 hours, the maximum dosage being 200 microg. When applied in the vagina, the dosage was twice 50 microg, every 6 hours. Four hours after the second dosage, if the effective delivery activity was not sufficient, we continued with sub-lingual application in dosage 50 microg every 4 hours till the regular delivery activity was reached. The vaginal delivery (childbirth) till the 24th hour of C application is considered as a successful induction. RESULTS: The delivery (childbirth) continuation, though with insignificant difference, is less under vaginal application. Uterine contractions begin (start) 30-35 minutes earlier under C application. Sectio Caesarea has smaller frequency under C application, in comparison with the general population frequency for the same period (year 2006 and the first half of 2007). The C induction is successful in 40 (88.89%), and with 7 (25.93%) the per oral application was prolonged via oxytocine infusion, and with half of the patients the vaginal application was continued via sun-lingual one. The author reaches the conclusion, that Cytotec is an effective and safe means for delivery (childbirth) induction, and that when dosage and application manner are set-up, the individual characterics of the patients should be taken into account. Mother-fetal results are the best under single dosage of 50 microg, applied in per oral, vaginal or sub-lingual way. Due to the wide application of Cytotec medicine, it is already high time to legalize it and to standardize the protocols from its application.

[Rear cases of tubal pregnancy during second trimester--diagnostic and therapeutic problems].

The lack of space abilities predetermine the fate of tubal pregnancy. Very often it disturbs in first few weeks. Preserving the tubal pregnancy after first trimester is very rear and often ends fatal. During 1970 in France the extrauterine pregnancy is met once on every 100 births. Now it is 2% from all births. In our country the relative part of ectopic pregnancy for last 20 years has grown twice. The authors represent two cases of tubal pregnancy, developed until second trimester, one of them ended fatal. The difficulties during diagnosing, characteristics of clinic and therapeutic problems are shown. Analysis are made on tendency of growing frequency of ectopic pregnancy, nevertheless modern diagnostic methods and also its role for maternal mortality.

[Carriers of thrombophilic factor among women with preeclampsia (preliminary report)].

The aim of this study was to determine whether inherited thrombophilia increases the risk of mild preeclampsia. Twenty five women who developed mild preeclampsia and 49 controls--women with previous uneventful pregnancies, were tested for factor V Leiden, C677T gene variant of methylenetetrahydrofolate reductase (MTHFR), polymorphism 4G/5G in plasminogen activator inhibitor 1 (PAI 1), polymorphism A1/A2 in platelet glycoprotein IIb/Illa (GIPrllb/llla A1/A2). The higher but not significant prevalence of C677T gene variant and polymorphism A1/A2 in women with preeclampsia compared with controls was found: 32% and 12.2%, respectively for cases and controls for both factors, with OR: 3.37 (95% CI 0.883-13.2), p > 0.05. The values of OR and RR for these two thrombophilic factors show that platelet integrin polymorphisms (GIPrIIb/llla A1/A2) and C677T gene variant might be have an important role for development of preeclampsia. The carriage of FVL was with a very small prevalence in women with preeclampsia (8%) as compared to controls (6,1%), with OR: 1.333 (CI 95% 0.143-10.864), p > 0.05. The similar results were found for carriage of polymorphism 4G/5G in PAI-1: gene, respectively 24% u 18.4% in women with preeclampsia as compared to controls, OR: 1.404 (95% CI 0.374-5.14), p > 0.05. The results are not significant, because of the small group of selected patients. Larger case-control study should be executed for the evaluation of impact of inherited thrombophilic factors in the development of mild preeclampsia.

[Risk of thrombophilia in carriers of thrombophilic genetic factors in unsuccessful assisted reproduction].

The aim of this study was to evaluate an association of carrier status of common inherited thrombophilic genetic mutations and implantation failure after assisted reproduction (ART): IVF and ICSI. Sixty seven women with failure of embryo implantation and ninety six controls--women without obstetric complication were investigated for carriage of factor V Leiden (FVL), G20210A prothrombin gene mutation, genetic variant C677T in methylentetrahydrofolate reductase gene (MTHFR) and polymorphism A2 in platelet glycoprotein IIb/IIIa (GIPr IIb/IIIa). A significantly higher prevalence of polymorphism A2 in GIPr IIb/IIIa was found in women with implantation failure in ART compared to controls (respectively 26.1% and 12.5%; OR: 2.571, 95% CI: 1.066-6.258, p = 0.033). A higher but not significant prevalence of G20210A prothrombin gene mutation carriage was found inpatients compared to controls (respectively 5.8% and 3.13%, OR: 1.968, 95% CI 0.356-11.539). The carriage of FVL was a little but not significantly higher in controls. The carriage of genetic variant C677T in MTHFR was the same in both groups. These data suggest that polymorphism A2 in GIPr IIb/IIIa and G20210A prothrombin gene mutation could be play a role in the etiology of IVF failures and the carriers of GIPr IIb/IIIa A1/A2 and G20210A prothrombin gene mutation are at higher risk of implantation failure and not successful ART outcome. The carriage of these two genetic defects should be investigated in women undergoing IVF and the antithrombotic or anticoagulant prophylaxis should be indicated for carriers of these two factors.

[Genetic variant C677T in the MTHFR in women with recurrent early fetal loss].

The aim of this study was to evaluate correlation of carrier status for thrombophilic gene mutation--C677T in the methylenetetrahydrofolate reductase (MTHFR) and recurrent early pregnancy loss. Recently inherited thrombophilia was discussed as a predisposed factor for early recurrent fetal loss (ERFL). We investigated carrier status for C677T genetic variant in 54 women with ERFL before 10 week of gestation and 67 women with one or more successful pregnancy. It was found significant prevalence of C677T genetic variant in MTHFR in women with ERFL compared with controls (p = 0.005). The significant high prevalence of C677T genetic variant in women with ERFL suggests that thrombophilia have an increased risk of early pregnancy loss and possibly, although the definition of the magnitude of risk will require prospective longitudinal studies.

[Ethical aspects of preliminary sex selection of the fetus].

With the emergence of preimplantation genetic diagnosis the perpetual trial of people to select their children's sex has become a scientific reality. This paper aims at making overview of the arguments for and against every social application of sex selection. More than 50 articles on the topic were reviewed, of which 19 that encompass different view points were chosen. The concept of family balancing itself is questionable. There are many arguments against. The predominant opinion in the profession, for the moment, is against every social application of sex selection technologies unless in cases of sex-linked diseases. As medicine and genetics develop further and further more complex ethical dilemmas arise. As individuals and members of society we need to think about what values our choices reflect and what consequences they are likely to have.

[Treatment of iron deficiency anaemia in pregnant, puerperal and gynaecological patients--different drugs, different approaches].

UNLABELLED: According to WHO about 50 per cent of women of fertile age have iron deficiency anaemia (IDA). Iron loss > 80 mg per month, with menstruation in 22 per cent of women cause a negative iron balance in the course of time. About 40 per cent of women have data of prelatent iron deficiency still before conception, and if the demands of occured pregnancy are added, IDA is quickly reached. Over 30 per cent of puerperal women are affected by anaemia. PURPOSE: To make a pharmacoeconomic assessment of peroral antianaemic drugs used for treatment of IDA in pregnant, puerperal and gynaecologically ill women. MATERIALS: There are presented- daily intake of drugs, number of drug package taken, the price of a drug package, value of treatment a month, reimbursement of the drugs below: Ferro Gradumet, Maltofer Fol, Sorbifer Durules, Tot'hema, Legofer, Ferro-Folgamma, Tardiferon. RESULTS: The survey made and the data of own studies show that the most important in treatment of IDA are the choice of iron- containing drug and the correct therapeutic approach. The choice of peroral iron- containing therapy is determined by: high "patient compliance"--good tolerance, independence on food intake, once daily intake, low frequency of adverse effects and treatment with low price (economic effect). CONCLUSION: The most suitable for treatment of IDA in pregnant and puerperal women are Maltofer Fol and Sorbifer Durules. Maltofer Fol is with the best correlation price: "patient compliance". Tot'hema and Legofer have a good tolerance, a few adverse effects, but they are with high price. Ferro folgamma has not a high "patient compliance" and it has comparatively high price. Ferro gradumet has a low price and low "patient compliance".

[Using ultrogestan for the treatment of spontaneous abortions and complications of climax in women with epilepsy].

Epilepsy is a disease, closely connected with sex-hormones and can lead to adverse repercussion on the reproductive health. The ovarial hormones influence excitation of neurocells membranes and have a lot of effects on brain, leading to provoking epileptic activity. The progesteron decrease and the estrogens increase the brain excitation, that's why estrogens (act like a proconvulsant) are proconvulsant and progesteron is anticonvulsant. The aim of this study is to evaluate therapeutic abilities of Utrogestan (micronising progesteron) for treatment of abortions and climacteric amplifications in women with epilepsy. The study is prospectiv and includes 21 women with epilepsy, treated with Utrogestan. The women are divided into two groups: 1-st group --12 pregnant women with symptoms of aborts and 2-nd group--9: 6 with climacteric blooding and 3 with hormone replacement therapy on the occasion of postcastration syndrome. In 13 patients drug is applied through mouth and in 8--through vagina. The vaginal way is used in patients, that accept enzyminductiv antiepilepsy drugs (AED). Utrogestan was applied preventive in 10 pregnant women with symptoms of danger of abortion and in two women with a medicinal aim. In 10 patient pregnancy finished successful with delivery of a healthy child on term, in one--pregnancy is in progress, in one was made interruption. There weren't epilepsy attacks in no one pregnant women, that may be connected with both adequate treatment of epilepsy and with influence of micronising progesteron as anticonvulsant. In the 2-nd group in 4 women with climacteric blooding Utrogestan is applied vaginal from 15-24 day of menstruation to retrieve regularity of cycles. In 3 women with postcastration syndrome Utrogestan is used as a part of hormone substitute treatment (Oestrogel and Utrogestan once a day continuously. The treatment was with very good effect, without changes in the frequency and weight of the epileptic attacks. Results of our study show, that Utrogestan has very good effect in treatment of women with epilepsy. With his natural, herbal origin and micronisation form, as well as possibilities for oral and vaginal application of the same form, Utrogestan tends to take the place of synthetic progesteron analogs, when epilepsy have had a bad influence over reproductive health.

[Sectio caesarea in extremely low birth weight newborn babies--modern tendency or objective necessity].

UNLABELLED: Obstetrician-gynecologists in a team with neonatologists contributed to saving of many children with extremely low birth weight /ELBW/, increasing many times SC frequency, considering it to be a sparing method for successful delivery, favorably influencing the outcome for the newborn. Many authors put emphasis on the better results however others point out reasons for a certain level of skepticism, assuming that survivability should not be the only criteria. Thus our objective was to find out the role of the abdominal delivery on the favorable outcome for ELBW newborn babies. MATERIAL AND METHODS: The study is retrospective, including 40 deliveries of children weighing from 500 to 999 g, at the Clinic in Obstetrics at Dr. Georgi Stranski University Hospital--Pleven, for a period of 5 years /2000-2004/. The newborn babies were divided into two groups depending on the method of delivery: I group--per vias naturales /PN/--31 cases--77.5% II group--per SC--9 cases--22.5%. RESULTS AND DISCUSSION: Attention was paid in our study to the most frequently asked question about the survivability of the newborn babies until their discharge, neonatal diseases and mortality rate, respectively. Survivability rate in the first group was 32.2% compared to 66.6% for the newborn babies per SC. The main reasons for mortality in the newborn babies are massive brain hemorrhages--70% of the cases, respiratory insufficiency--25% and extreme immaturity--5%. CONCLUSIONS: 1. Operative delivery is an objective necessity as a method improving the final favorable outcome for ELBW newborn babies. 2. The intensive neonatal cares accompanied by precise application of surfactant sharply increase the survivability rate and reduce diseases and mortal rate of ELBW newborn babies. 3. The preventive cares in the maternity consultation rooms could become a landmark for reducing the number of pre-term deliveries.

[Anticonvulsive therapy in eclampsia--its current status]. / Protivogurchova terapiia pri eclampsia--suvremenno stanovishte.

Conflicting opinions on the adequate and appropriate anticonvulsive therapy for eclampsia stems from the fact that a lot of unclarity still exists as per the reasons for eclamptic seizures. The authors reviews current data from literature on the problem of anticonvulsive therapy for eclampsia and tries to clarify the uncertainties on the optimal approach for eclamptic seizures. Despite the fact that many neurologists in the U.S. as well as a great number of obstetricians in Europe are now sceptical about the anticonvulsive effect of magnesium sulphate and prefer other anticonvulsive agents, the parenteral application of magnesium is still the principal approach for eclampsia. There is a need however for a new strategy for prophylaxis and therapy of eclampsia. Which will lead to a significant reduction of the fatality rate in cases of grave preeclampsia-eclampsia.

[A breech delivery and induction with prostaglandin E2]. / Sedalishtno razhdane i induktsiia s prostaglandin E2.

Induction of labour with local application of PgE2 in breech presentation is still a much discussed problem. We aimed at studying the effect of local application of PgE2 (Prostin E2--3 mg) vaginal tablets for induction of labour in breech presentation. 15 pregnancies were studied and induced--8 for postdate, 6 for prae-eclampsia and 1 for fetal demise. Sonographic biometry and cardiotocographic examinations were conducted as well as a precise bishop score. Labour began within the interval of 3-13 hours after the application on the first tablet. The length of delivery was 4-24 hours. Effective labour was instituted in 93.33% on the parturiens, while in 1 (6.67%) there was a need for augmentation with oxytocin. There were no cases of hyperstimulation. Vaginal delivery was accomplished in 100% of the patients among which the breech was delivered with the classical manoeuvre in 10 cases and by the Bracht manoeuvre in 5 cases. Our results show, despite is small case number, that with favourable pelvic scores and absence of cephalopelvic disproportion and fetal distress PgE2 induction can be done locally even for breech presentation.

[The use of the Norcolut preparation in gynecologic; practice]. / Prilozhenie na preparata Norkolut v ginekologichnata praktika.

The author's aim is to study the therapeutical possibilities and the side effects of Norkolut preparation, produced by the Pharmaceutical Plant Gedeon Richter-Budapest. Norkolut is a peroral gestagen containing 5 mg noretisteron in 1 tablet. The study included 40 women, age 17 to 52 who had been administered the preparation from 1 to 6 menstrual cycles--total 162. The main indications for its application were: climacteric bleeding with proved cystic hyperplasia, irregular menstrual cycles, myoma uteri cum metrorrhagia, perimenopause hormone replacement therapy, adenomyosis. The recorded effect of the preparation was very good with little side effects (7.5%). The author's conclusion is that Norkolut is quite suitable to be used in the everyday gynaecological practice in the treatment of the dysfunctional uterus bleeding, irregular menstrual cycles, in the hormone replacement therapy during menopause and for decreasing the complaints in adenomyosis.

[Criteria for the antenatal diagnosis of chronic fetal hypoxia in certain forms of high-risk pregnancy]. / Kriterii za antenatalna diagnoza na khronichnata fetalna khipoksiia pri niakoi formi visokoriskova bremennost.

The author aimed to compared and simultaneously interpret results from cardiotocographic, ultrasound and hormonal studies and to establish objective criteria, showing the degree of antenatal risk for the fetus. She investigated 176 pregnant women with EPH--gestosis, 136 women with chronologically prolonged pregnancy and 50 healthy pregnant women as a control group. Non stress test (NST, functional oxytocin test, quantitative and semiquantitative evaluation of cardiac frequency of the fetus (CFF) were made. Placental structure was examined by an echograph, as well as the amount of amniotic fluid. Fetal biometry was made as well. Total estrogens (TE) were determined in 24-hour diuresis. It was established that the normal curve of NST was a sign of fetal well-being, but that curve combined with deceleration, together with low values of TE, were criteria for reduced compensatory possibilities of the fetus. NST with decelerations in Braxton Hicks contractions, even part greater than 80% and "terminal" or sharply falling values of TE were signs impending fetal death.

[The current treatment of genital endometriosis]. / Suvremenno lechenie na genitalnata endometrioza.

Three therapeutic strategies are available in treating genital endometriosis (GE): medical treatment only, surgical treatment only and a combination of both, i.e. medical and surgical treatment. The author reviews the combined approach to different forms of GE, namely: cervical, ovarian, tubal, adenomyosis, retrocervical, vaginal and perineal. The common problems in decision making are: the age of the patient and her reproductive function, the localization, spread and stage of the lesion, the possible coexisting inflammatory process and its sequellae, the endometrial hyperplasia and the destructive changes of the uterus and ovaries. Hormonal drugs of choice are the anti-gonadotropin danazol and the GnRH analogues. Introduction of argon, CO2 and YAG lasers proved effective in treating certain forms of GE. Therapy results depend on the severity and spread of the process, on resection volume and completeness, on full scale hormonal therapy as well as on rehabilitation. Close follow-up, including ultrasound examination every 3 months, should be provided for immediate detection of possible side effects and complications.

[Acute appendicitis and pregnancy]. / Ost'r apenditsit i bremennost.

The authors summarize the special characteristics of the acute appendicit and the pregnancy. He pays attention on the symptoms, which made the diagnosis, laboratory analyses and differences with the most common obstetrics-gynaecological diseases. We have studied the main surgical techniques for make operation during Caesarean section. In the cases when there are noncomplicated delivery and acute appendicitis, we have to make an operation and the delivery occurs normal vaginal.

[Pregnancy and labor in young girls]. / Bremennost i razhdane pri mladi momicheta.

The premature sexual contacts in adolescence are the most important factor for the high rate of teenage pregnancies. The authors were observed 528 pregnancies in adolescent girls (aged 13-17 years) and 100 mothers at their 20-24 years, as a control group. There were significant differences between the education level, ethnic origin and professional status in our populations. We founded in adolescent group anaemia in 13.64%, an overweight in 6.44% and preeclampsia-eclampsia in 3.22%. The rate of premature delivery was higher (17.99%), caesarean section were performed in 5.44% and instrumental extraction was practiced in 1.70% of adolescent girls. Despite an pregnancy and delivery with a normal evolution, the mother-fetal prognoses were complicated from the hard psychoemotional, social and economical problems about these young mothers.

PIP: 528 pregnancies of primiparous girls 13-17 years old who gave birth during 1988-90 at the obstetrical ward of the city of Pleven, Bulgaria, were evaluated. The pregnancy outcome and neonatal results were compared with those of 100 controls. These 528 births amounted to 5.48% of a total of 9635 births at the clinic. These girls were of low socioeconomic status, 14.2% were illiterate or had low educational attainment, and 56.42% were of Gypsy origin, without skills, and from rural areas. Only 32.89% of the Bulgarian girls had an official marriage license. Anemia was found in 13.64%, kidney infection (without symptoms of bacteriuria, pyelonephritis) in 6.44%, preeclampsia in 2.46%, and eclampsia in 0.76%. The most frequent occurrence was premature rupture of the membrane (9.85%). Term deliveries numbered 433 and preterm deliveries 95. There was a statistically significant difference between the two groups with respect to term and preterm deliveries (p 0.01). Dystocia amounted to 2.8% and instrumental delivery to 1.70% among these adolescent girls. The rate of premature delivery reached 17.99%, and cesarean section was performed in 5.44%. There was a significant difference between the two groups with respect to vaginal delivery (p 0.01) and cesarean section (p 0.01). 44% of 16-year old girls underwent cesarean section; and there was a significant difference in the rate of cesarean section between 14-year-old and 17-year-old girls (p 0.05) as well as between 16-year-old and 17-year-old girls (p 0.01). 71.95% of newborns had a birth weight of less than 3000 g. There was also a significant difference between the groups with regard to term and prematurely born neonates (p or = 0.01). Intrauterine growth retardation reached 2.46% because of the inadequate uterine size of girls 13-14 years old, insufficient weight gain during pregnancy (under 9 kg), and complications (preeclampsia and eclampsia). The rate of stillbirths was 7.63%, attributed to prematurity and malformation of the fetus. Maternal mortality reached 1.89% owing to pregnancy complications (eclampsia) among 17-year old girls because of low socioeconomic status and complete lack of prenatal care.

[Current management in pregnancy and epilepsy]. / Suvremenno povedenie pri bremennost i epilepsiia.

Modern treatments make possible uneventful pregnancy and successful delivery for most of the epileptic women. Major risks however remain the teratogenic effects of some antiepileptic drugs and the obstetric complications they may cause. This implies careful planning of pregnancy for women with epilepsy and alertness for possible unwanted or undiagnosed (in the early stages) pregnancy in epileptic women during their reproductive years. The authors summarize current opinions in drug selections, specific treatment regimens and the obstetrics problems during pregnancy and delivery in epileptic women.

[Current position on the treatment and prevention of pre-eclampsia-eclampsia with magnesium sulfate]. / Suvremenno stanovishte otnosno lechenie i profilaktika s magneziev sulfat pri preeklampsiia-eklampsiia.

The study was retrospective, encompassing 2 years period of time (2000-2001), as it was carried out at the First and the Second Clinics of Obstetrics at the Higher Institute of Medicine-Pleven. Fifty pregnant women and women in-child-birth having Praeeclampsia-Eclampsia (PE-E) were treated during this period, as 26 of them were administered Cormagnesin (first group) and 24 (second group) were not treated with magnesium preparations. In the first group 6 pregnant women had severe PE and 4-E, total 10 (38.4%). All E pregnant women and the PE cases with RR > or = 180/120 were treated with Cormagnesin. In the second group there were 4 pregnant women with severe PE (16.67%) but proteinuria was predominant (> or = 5 g/l) as RR was not higher than 160/110, so we did not have the reason to administer them Cormagnesin. The highest total dose MgS was 100 g and it was applied only in 1 E case (20g /daily for the duration of 5 days). In the remaining E cases the total dose was 60, 48, 2 g, respectively, as the number of applications was from 1 to 4 times daily, and the duration from 1 to 4 days. Cormagnesin gave excellent results in 80% of the cases with severe PE-E. The frequency rate of s.c. in the first group was 57.69%, in the second group--25%. The authors made the conclusion that the severity of PE-E and mainly the high values of RR and the other accompanying symptoms determined treatment with MgSO4. Cormagnesin application scheme was strictly individual. MgSO4 application allowed the possibility for conducting the delivery under more favourable conditions when convulsions were under control and RR was stabilised.