Management of pregnant female with Haemophilia-A: A case report.

Haemophilia-A is a rare, X-linked recessive inherited disease affects males and females are carrier results in prolonged bleeding after minor injuries, procedures or surgery. Spontaneous or recurrent bleeding may occur in deep muscles, joints but intracranial haemorrhage can be dangerous. Women with a family history of bleeding disorder, personal history of bleeding (menorrhagia, mucous membrane, postoperative bleeding and PPH) or a prolonged activated partial thromboplastin time (aPTT) should be screened for haemophilia by measuring coagulation factor VIII level during hospital visits for these reason or antenatal care (ANC). Female heterozygote carriers may have variable presentation of bleeding due to reduced levels of clotting FVIII and may experience excessive bleeding due to gynaecologic issues, during spontaneous abortion, medical termination of pregnancy or invasive prenatal diagnostic techniques in first trimester of pregnancy, antepartum and postpartum haemorrhage in later part of gestation and after delivery.

To Study the Vitamin D Levels in Infertile Females and Correlation of Vitamin D Deficiency with AMH Levels in Comparison to Fertile Females.

CONTEXT: Human and animal data suggest that low vitamin D (25-hydroxyvitamin D) status is associated with impaired fertility, endometriosis, and polycystic ovary syndrome. Vitamin D regulates antimullerian hormone (AMH), FSH, mRNA, and expression of genes in reproductive tissues, implicating a role in female reproduction. AIMS: To study the vitamin D levels in infertile females and to know the correlation of vitamin D deficiency (VDD) with serum AMH in infertile females compare to fertile females. SETTINGS AND DESIGN: This prospective study was conducted in department of Maternal and Reproductive Health in between April 2014 and April 2016. MATERIALS AND METHODS: After matching inclusion and exclusion criteria out of total 70 infertile females, 45 were found to have VDD. Of these 35 patients were identified as cases; in whom, the AMH levels were assessed. As control 35 fertile normal females were taken, in which vitamin D and AMH were taken. In both groups, correlation of VDD with AMH was studied. STATISTICAL ANALYSIS USED: To analyze the correlation between vitamin D and AMH linear regression test and for comparison of both the groups, two sample t tests were used. RESULTS: The VDD was present in 64.28% of infertile females. In vitamin D deficient cases, the mean for vitamin D was 6.18 ± 2.09 and AMH was 1.94 ± 1.30. In vitamin D deficient controls, the mean for vitamin D was 4.85 ± 3.02 and AMH was 3.47 ± 2.59. On comparison, the vitamin D levels were lower in fertile than infertile females, which was significant (P = 0.04), and AMH levels were lower in cases than control group (P = 0.003). CONCLUSION: The VDD was present in 64.28% of infertile females. No significant correlation was found in between VDD and AMH levels in both the groups.

Spontaneous successful pregnancy in posthypophysectomy hypopituitarism: A rare case report.

Pregnancy in patients with pan-hypopituitarism following surgery of pituitary adenoma is rare and considered high risk. Hormonal dysfunction in these patients involves more than one axis (gonadotrophic, thyroidal, and adrenal). However, advance in infertility treatment have led to the increased pregnancy rate in hypopituitarism women. We present a case of nonfunctioning pituitary macroadenoma, who after pituitary surgery (hypophysectomy) developed hypopituitarism followed by multiple tuberculoma brain with hydrocephalus with arachnoiditis. She conceived spontaneously after 9 years of pituitary surgery and carried her pregnancy to the term. Elective caesarean section was done at 38 weeks and both infant and mother are well. The case highlights the rarity of the phenomenon and the safe outcome of the pregnancy with proper replacement.

Hepatobiliary diseases during pregnancy and their management: An update.

Liver diseases in pregnancy although rare but they can seriously affect mother and fetus. Signs and symptoms are often not specific and consist of jaundice, nausea, vomiting, and abdominal pain. Although any type of liver disease can develop during pregnancy or pregnancy may occur in a patient already having chronic liver disease. All liver diseases with pregnancy can lead to increased maternal and fetal morbidity and mortality. It is difficult to identify features of liver disease in pregnant women because of physiological changes. Physiological changes of normal pregnancy can be confounding with that of sign and symptoms of liver diseases. Telangiectasia or spider angiomas, palmar erythema, increased alkaline phosphatase due to placental secretion, hypoalbuminemia due to hemodilution. These normal alterations mimic physiological changes in patients with decompensated chronic liver disease. Besides all these pathological changes however, blood flow to the liver remains constant and the liver usually remains impalpable during pregnancy. The diagnosis of liver disease in pregnancy is challenging and relies on laboratory investigations. The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly. If we see the spectrum of liver disease in pregnancy, in mild form there occur increase in liver enzymes to severe form, where liver failure affecting the entire system or maternal mortality and morbidity. It can not only complicate mother's life but also poses burden of life of fetus to growth restriction. Most of the times termination is only answer to save life of mother but sometimes early detection of diseases, preventive measures and available active treatment is helpful for both of the life. Extreme vigilance in recognizing physical and laboratory abnormalities in pregnancy is a prerequisite for an accurate diagnosis. This could lead to a timely intervention and successful outcome.

Management of paroxysmal hypertension due to incidental pheochromocytoma in pregnancy.

A 25-year-old, full-term pregnant woman diagnosed with pre-eclampsia was referred to our tertiary care hospital with severe resistant hypertension. Her blood pressure remained labile despite the usual medications, which led to the suspicion of an underlying endocrinological problem. Further biochemical and radiological investigations confirmed the diagnosis of pheochromocytoma. The patient was invasively monitored and treated with alpha blockade, beta blocker, and vasodilators. The primary goals for the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery, and definitive surgical treatment. This case illustrates that one needs to be cautious when such a presentation of paroxysmal hypertension is present. With a multidisciplinary team approach, proper planning, and adequate preoperative medical management, pheochromocytoma in pregnancy can be managed successfully.

Gossypiboma, a rare cause of acute abdomen: A case report and review of literature.

Gossypiboma or textiloma is used to describe a retained surgical swab in the body after an operation. Inadvertent retention of a foreign body in the abdomen often requires another surgery. This increases morbidity and mortality of the patient, cost of treatment, and medicolegal problems. We are reporting case of a 45-year-old woman who was referred from periphery with acute pain in abdomen. She had a surgical history of abdominal hysterectomy 3 years back, performed at another hospital. On clinical examination and investigation, twisted ovarian cyst was suspected. That is a cystic mass further confirmed by abdominal computerized tomography (CT). During laparotomy, the cyst wall was opened incidentally which lead to the drainage of a large amount of dense pus. In between pus, there was found retained surgical gauze that confirmed the diagnosis of gossypiboma.

Revisiting hemophilia management in acute medicine.

The World Federation of Hemophilia estimates that more than 350,000 people globally have a form of the disease. Hemophilia A is a bleeding disorder that has a spectrum of manifestations ranging from persistent bleeding after minor trauma to spontaneous hemorrhage. We report a case of a male patient with hemophilia A who received general anesthesia for removal of foreign body from the nose. There was no excessive blood loss during surgery. Perioperatively, the patient received recombinant factor VIII coverage. Rest of the postoperative course was uneventful. Literature on the clinical management of patient with hemophilia A are reviewed and considerations for perioperative preparation and management of hemophilic patient are presented.

Anaesthetic management of Wolff-Parkinson-White syndrome for hysterectomy.

Wolff-Parkinson-White syndrome (WPW) is an uncommon cardiac disorder having an aberrant pathway between atria and ventricles. We are reporting a known case of WPW syndrome for hysterectomy under combined spinal epidural anaesthesia. Management of the present case is an important pearl to revisit management of WPW syndrome. The perioperative management should be tailored according to the nature of surgery and the clinical presentation of the patient.

Simulation in resuscitation teaching and training, an evidence based practice review.

In the management of a patient in cardiac arrest, it is sometimes the least experienced provider giving chest compressions, intubating the patient, and running the code during the most crucial moment in that patient's life. Traditional methods of educating residents and medical students using lectures and bedside teaching are no longer sufficient. Today's generation of trainees grew up in a multimedia environment, learning on the electronic method of learning (online, internet) instead of reading books. It is unreasonable to expect the educational model developed 50 years ago to be able to adequately train the medical students and residents of today. One area that is difficult to teach is the diagnosis and management of the critically ill patient, specifically who require resuscitation for cardiac emergencies and cardiac arrest. Patient simulation has emerged as an educational tool that allows the learner to practice patient care, away from the bedside, in a controlled and safe environment, giving the learner the opportunity to practice the educational principles of deliberate practice and self-refection. We performed a qualitative literature review of the uses of simulators in resuscitation training with a focus on their current and potential applications in cardiac arrest and emergencies.

Management of pregnant female with meningioma for craniotomy.

Intracranial meningioma during pregnancy challenges the skill of obstetricians, neurosurgeons and neuroanesthesiologists in resection of the tumor and to secure delivery of the baby. Advances in fetal and maternal monitoring, neuroanesthesia, and microsurgical techniques allow safe neurosurgical management of these patients. Urgent neurosurgical intervention is reserved for the management of malignancies, active hydrocephalus, and benign brain tumors associated with signs of impending herniation or progressive neurological deficit. Particular attention is given to maintain stable maternal hemodynamics to avoid uterine hypo perfusion and fetal hypoxia intraoperatively. Therefore, the major challenge of neuroanesthesia during pregnancy is to provide an appropriate balance between competing, and even contradictory, clinical goals of neuroanesthesiology and obstetric practice.

Better outcome after pediatric resuscitation is still a dilemma.

Pediatric cardiac arrest is not a single problem. Although most episodes of pediatric cardiac arrest occur as complications and progression of respiratory failure and shock. Sudden cardiac arrest may result from abrupt and unexpected arrhythmias. With a better-tailored therapy, we can optimize the outcome. In the hospital, cardiac arrest often develops as a progression of respiratory failure and shock. Typically half or more of pediatric victims of in-hospital arrest have pre-existing respiratory failure and one-third or more have shock, although these figures vary somewhat among reporting hospitals. When in-hospital respiratory arrest or failure is treated before the development of cardiac arrest, survival ranges from 60% to 97%. Bradyarrthmia, asystole or pulseless electric activity (PEA) were recorded as an initial rhythm in half or more of the recent reports of in-hospital cardiac arrest, with survival to hospital discharge ranging from 22% to 40%. Data allowing characterization of out of hospital pediatric arrest are limited, although existing data support the long-held belief that as with hospitalized children, cardiac arrest most often occurs as a progression of respiratory failure or shock to cardiac arrest with bradyasystole rhythm. Although VF (Ventricular fibrillation, is a very rapid, uncoordinated, ineffective series of contractions throughout the lower chambers of the heart. Unless stopped, these chaotic impulses are fatal) and VT (Ventricular tachycardia is a rapid heartbeat that originates in one of the ventricles of the heart. To be classified as tachycardia, the heart rate is usually at least 100 beats per minute) are not common out-of-cardiac arrest in children, they are more likely to be present with sudden, witnessed collapse, particularly among adolescents. Pre-hospital care till the late 1980s was mainly concerned with adult care, and the initial focus for pediatric resuscitation was provision of oxygen and ventilation, with initial rhythm at the time of emergency medical services arrival being infrequently recorded. In the 1987 series, pre-hospital pediatric cardiac arrest demonstrated asystole in 80%, PEA in 10.5% and VF or VT in 9.6%. Only 29% arrests were witnessed, however, and death in many victims was caused by sudden infant death syndrome.

Estimation of the Incidence of Bacterial Vaginosis and other Vaginal Infections and its Consequences on Maternal/Fetal Outcome in Pregnant Women Attending an Antenatal Clinic in a Tertiary Care Hospital in North India.

AIMS: This study was undertaken to estimate the incidence of bacterial vaginosis (BV) and other vaginal infections during pregnancy and its association with urinary tract infections (UTI) and its consequences on pregnancy outcome, maternal and fetal morbidity and mortality. SETTINGS AND DESIGN: Prospective cohort study. MATERIALS AND METHODS: The present prospective cohort study was conducted on 200 women attending the antenatal clinic (ANC) of a tertiary hospital. All pertinent obstetric and neonatal data covering antenatal events during the course of pregnancy, delivery, puerperium and condition of each newborn at the time of birth were collected. BV was detected by both Gram stain and gold standard clinical criteria (Amsel's composite criteria). STATISTICAL ANALYSIS USED: Data were analyzed using SPSS version 9. Fischer's exact test, chi square tests and Student's' test has been used for analysis. The probability of 5% was considered as significant for continuous variables such as age, period of gestation and birth weight. Odds ratio (OR) and confidence interval (CI) with 95% probability were determined. RESULTS: The incidence of bacterial vaginosis was 41 in 200 patients. Adverse outcomes such as preterm labor, PROM and fetal complications were found more in pregnant women who had bacterial vaginosis (N=41), bacterial vaginosis with UTI (N=14) as compared to those without bacterial vaginosis (N=118). CONCLUSIONS: The incidence of poor pregnancy outcome was higher in bacterial vaginosis with UTI. Prevention of BV and UTI is cost effective to minimize the pregnancy-related complications and preterm labor to decrease in perinatal and maternal mortality and morbidity. We recommend all antenatal patients should be screened for the presence of bacterial vaginosis, other infections and UTI.

Respiratory depression during VP shunting in Arnold Chiari malformation Type-II, a rare complication (Case reports and review of literature).

The VP Shunt is a common pediatric surgical procedure in our country. Hydrocephalus is commonly associated with meningomyelocele in Arnold Chiari malformation-II and the ventriculoperitoneal shunt insertion is the common surgical procedure for the management of hydrocephalus. The standard protocol is to rule out any hydrocephalus by preoperative MRI. If associated with hydrocephalus, insertion of the VP shunt is indicated before the repair of MMC whereas the absence of hydrocephalus indicates that the surgical repair of MMC is to be undertaken immediately. Anesthetic management of the patient during the insertion of ventriculoperitoneal shunt may pose problems. We report here two cases of ACM-II (lumbar MMC with associated hydrocephalus) who had respiratory depression / delayed emergence after an otherwise uneventful procedure. Although the VP shunt (first procedure) required postoperative ventilation which improved later, the phenomena of respiratory depression / delayed emergence did not occur after the MMC repair (second surgery). The possible mechanisms involved in these events and their various clinical aspects are discussed below.

Emergency intubation using a light wand in patients with facial trauma.

Airway management in the operating room is the responsibility of anesthesiologists, although a variety of personnel may be responsible for airway management outside the operating room. Emergency department physicians are prominently involved in airway management in the emergency room both independently and with anesthesiologists. Airway management in trauma patients remains the domain of anesthesiologists. An 18-year old male patient was brought to our emergency room after an alleged history of suicidal attempt with gunshot under the chin. He was scheduled to undergo emergency tracheotomy, debridement, and closure of facial laceration under general anaesthesia, presenting a challenge for. He had to undergo emergency tracheotomy, debridement, and closure of facial lacerations under general anesthesia. The injuries made the patient's airway management a complex issue. We present the use of the light wand to manage the difficult airway of this patient with complex facial trauma.

Emergency management of decompensated peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women.[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m(2) body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.