Women with Turner's syndrome have a high incidence of cardiovascular complications, endocrine and hypertensive disorders. Those with the 45X chromosome complement require oocyte donation and in vitro fertilisation to conceive. Pregnancies in such women are challenging to manage due to the high risk of pregnancy-related hypertensive disorders, impaired glucose tolerance, fetal growth restriction and preterm birth. Women also need to be aware of the significant risk of aortic dilatation, dissection or rupture in pregnancy, which may be fatal. Despite these risks, favourable obstetric outcomes are achievable with careful pre-pregnancy counselling and cardiovascular assessment, intensive multidisciplinary antenatal monitoring and individualised delivery planning. We report the case of a 33-year-old woman with Turner's syndrome, pre-existing hypertension, insulin-dependent diabetes and primary hypoparathyroidism who had a successful pregnancy with good maternal and fetal outcomes despite the complexity of her medical conditions. Keywords High-risk pregnancy, diabetes, hypertension, infertility, Turner's syndrome Case reportA 33-year-old woman diagnosed with Turner's syndrome in childhood became pregnant after five cycles of in vitro fertilisation (IVF) with donor oocytes. She suffered from recurrent ear infections as a child, necessitating an adenoidectomy and myringotomy aged four. Karyotyping performed at the age of 10 due to short stature (126 cm) revealed monosomy 45X. She received growth hormone until the age of 16 to induce adult height. Oestradiol was commenced at age 13 to stimulate puberty, then switched to combined sequential hormone replacement therapy to protect the endometrium and induce progesterone withdrawal bleeds. Cardiac imaging revealed a small subaortic membrane with no significant gradient across the left ventricular outflow tract (peak of 12 mmHg only), good left ventricular function and no coarctation or dilatation of the aorta. She attended for annual echocardiogram and cardiology review and remained asymptomatic. She was admitted to hospital with persistent vomiting aged 22, found to be in diabetic ketoacidosis and diagnosed with type 1 diabetes. At the age of 27, she developed hypertension which was treated with lisinopril. She attended for pre-pregnancy counselling aged 28. Her height was 153 cm, weight 62 kg and BMI 26. Her antihypertensive medication was changed to methyldopa, as angiotensin-converting enzyme inhibitors are contraindicated in pregnancy. She commenced folic acid 5 mg daily. With the support of the diabetes team over the next four years, she reduced her HbA1c from 8.4% to obtain optimal glycaemic control with a continuous subcutaneous insulin pump. She also underwent laser treatment for diabetic retinopathy.Her fifth IVF cycle was successful and supported by oestradiol, progesterone, prednisolone, aspirin and low-molecular-weight heparin (LMWH). She received intralipid infusions on days 4-9 of her IVF treatment protocol in a research context, as investigations for ...
Objective: Rapid-access chest pain clinics, typically run by doctors, allow the rapid assessment of suspected new-onset angina. Five years ago specialist nurse-led rapid-access chest pain clinics were established at Royal Albert Edward Infirmary. The objective of this audit was to assess safety and effectiveness of these clinics. Method: Retrospective data were collected from all patients from January 2002 to December 2006. Results: GPs referred 1464 patients. Of those, 1349 (92.14%) patients were seen within the 14-day government target. The clinic had 1417 (96.8%) patients who under went exercise testing and 234 (16%) of these were positive. Of those patients 143 (61.8%) under went cardiac catheterization. Coronary artery disease was found in 110 patients. Eighty one patients under went revascularization and 29 patients were treated medically. Conclusions: This audit demonstrates that specialist nurse–led rapid -access chest pain clinics are safe and effective. They identify patients who are more likely to have coronary artery disease, therefore allowing early medical/surgical intervention and reducing patient morbidity and mortality. The burden on doctors is reduced and government targets are met.
Paracetamol is the most common drug employed in self-poisoning in the UK, with 25,000 admissions from paracetamol poisoning recorded in 2001 alone [Morgan et al. 2005]. The toxic effects of paracetamol on the hepatic and renal systems are well documented, but it is less publicized that paracetamol and its metabolites can have toxic effects on other organ systems including the myocardium [Jones and Prescott, 1997]. We present a case of paracetamol poisoning causing toxic myocardial damage. Case report A 68-year-old woman self-presented 12 h after taking a 25-g paracetamol overdose. She had no past medical history of note and was not currently taking any medications. Clinically she was asymptomatic but was noted to be mildly hypotensive. Serum paracetamol level at presentation was 23 mg/l (reference range: 1020 mg/l at 4 h post-ingestion), but other blood results including arterial blood gases were unremarkable.
SUMMARYTo assess clinical outcomes and lifestyle modifications in diabetic patients attending a standard cardiac rehabilitation programme following myocardial infarction (MI), a retrospective longitudinal study was undertaken in a district general hospital in the north west of England. A total of 1804 patients attended the cardiac rehabilitation programme over 10 years, of whom 223 (12.4%) had diabetes mellitus. Drugs were underprescribed in all patients, aspirin and beta‐blockers especially in diabetics (75.3% vs 90.3%, p<0.0001; 38.6% vs 60.8%, p<0.0001). Smoking cessation was poor in diabetics (54.2% vs 69.1%, p<0.003) and diabetics were less likely to attend at least one session of physiotherapy (26.9% vs 58.6%, p<0.0001). Diabetics had higher mortality at one year (15.7% vs 5.6%; p<0.0001), mostly associated with cardiovascular disease (13.4% vs 5.4%, p<0.0001). Standard cardiac rehabilitation programmes appear to be less effective for patients with diabetes mellitus. We suggest that patients presenting with an existing chronic condition need specialised programmes of rehabilitation to integrate the care of that condition with their recent MI. Aggressive drug therapy following acute MI should also be prescribed in all patients when not contraindicated by other evidence.
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