Management of a pregnant patient with mechanical heart valve is a complex issue for all health care providers involved in the care of such patients. Complications may arise at any stage due to the increased haemodynamic load imposed by pregnancy or because of impaired cardiac performance often seen in these patients. In addition, the use of various cardiovascular drugs in pregnancy (especially anticoagulants) may lead tofoetal loss or teratogenic complications. Additionally, the risk of thrombo-embolic complications in the mother is increased by the hypercoagulable state of pregnancy. In this review, we have attempted to draw inferences to guide management of such patients based on the available literature. It seems that in pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labour. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Unfortunately there is no consensus on such data. An overview of the available literature forms the basis of this review. In conclusion, a guideline comprising pragmatic considerations is preffered.
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Patients with congenitally unguarded tricuspid valve orifice, along with associated abnormalities, rarely survive till adulthood. We report such a case, with a hypoplastic right ventricle and a floating thrombus in a giant right atrium, with intact interatrial and interventricular septa. The patient was managed surgically with satisfactory outcome. (Ind J Thorac Cardiovasc Surg, 2007; 23: 272-274)
SUMMARY: A 38 year old Caucasian lady presented with a history of vague ill health, raised ESR and prolonged P-R interval on ECG. These features became normal within a week. Contrary to the usual presentation, this patient developed fleeting arthritis, one of the major diagnostic features of rheumatic fever, towards the end of her illness. It is important to recognise such variants of rheumatic fever, even in retrospect, for the sake of giving penicillin prophylaxis to prevent cardiac morbidity. IntroductionThe incidence of rheumatic fever (RF) has decreased so much in recent years in the West, that it is extremely rare to find such cases in general medical practice. It usually affects children between 5 and 15 years of age. Cases of RF should fulfil at least one major and two minor of the revised Duckett lones criteria (Table 1) for the diagnosis to be made, supported by culture or serological evidence of recent streptococcal infection (1). In most cases enough features are present to make a working diagnosis at the onset of the illness. In some cases, however, it is difficult to reach a definite diagnosis due to the lack of sufficient features in the early stages. A period of careful follow up with a high index of suspicion for evolving features of RF, will help reach a diagnosis in such cases. I have presented here one such case of an adult female where the diagnosis of RF was not possible early in her illness, but who developed migratory joint symptoms later. It emerged on review of the overall clinical picture that she had sufficient diagnostic features to make a firm diagnosis of RF.Case Report A 38 year old Caucasian housewife was admitted to the hospital with a history of dizziness on standing, feeling faint and general malaise. She had had a flu-like illness with sore throat a week before the onset of these "now Consultant Physician, BMH Rinteln, BFPO 29 symptoms. She had no other relevant past medical history or family history. She denied taking any drugs, apart from aspirins at the beginning of her illness.On examination she had a variable pulse rate of 80-100 per minute, with postural hypotension (recumbent BP 110/60 and on standing 80/60). Her skin was tanned. Otherwise examination was normal.Investigations revealed a WBC count of 14.3 x 10 9 /L, haemoglobin 14.5 gmOJo, ESR 100mm/lst hour. An ECG showed marked prolongation of P-R interval (0.28 secs) (Fig la+ b). Other investigations, including urea electrolytes, plasma cortisols, liver function test, blood culture, blood glucose, cardiac enzymes, serum calcium and chest X-ray were normal. An echocardiogram did not reveal any evidence of aortitis or vegetation on the valve cusps. The result of her autoantibody profile, ANF, rheumatoid factor and syphilis serology were reported normal.The prolonged P-R interval and ESR returned to normal within a week without specific treatment (Fig lc). She was discharged, but a week later she was readmitted with pain and swelling in her right ankle, followed, over the next two weeks, by joint symptoms in her ri...
Background and aims Myasthenia gravis (MG) is a heterogeneous disorder in which antibodies are directed at the postsynaptic membrane of the neuromuscular junction, leading to varying degrees of muscle weakness and fatigability. Ptosis, dysphagia, dysphonia and proximal weakness are common presenting symptoms in children. We report a case of 14 months old male child presenting with inspiratory stridor resembling group. Methods and results A 14 months old child presented to accident and emergency (A&E) of a district general hospital for the third time in a week, with barking cough, noisy breathing and stridor. His symptoms had worsened over the last 24 hours resulting in a choking episode and difficulty in feeding. This was preceded by a week's history of cough, cold, diarrhoea and vomiting. He was treated as croup on first two attendances in A&E. He was born at term by normal vaginal delivery to unrelated Caucasian parents. He was diagnosed with laryngomalacia at two months of age, when he presented to paediatric outpatients for noisy breathing. This improved by 6 months of age. There was no family history of neuromuscular disorders. Examination revealed tachycardia, signs of respiratory distress, stridor, drooling from mouth and drooping eyelids. He was transferred to tertiary centre for intensive monitoring and further investigations. His initial treatment based on a presumptive diagnosis of croup did not show any response. Further investigations included MRI brain which was normal. After a failed extubation, he was subjected to tensilon test to which a partial response was noted. He was commenced on pyridostigmine and prednisolone. Repetitive nerve stimulation and stimulated single fibre electromyography confirmed the diagnosis of MG. Acetyl choline receptor antibodies were undetectable. Results of genetic screening are still awaited. Prednisolone was weaned in next 4- 6 months. He remains well on pyridostigmine. Conclusion Myasthenia gravis can present with involvement of any muscle innervated by cranial nerves and the diagnosis should be entertained when muscular weakness or fatigability is demonstrated. Although an uncommon cause Myasthenia gravis should be included in differential diagnosis of stridor.
A high index of suspicion is required to pick up cases of subdural empyema in clinical practice. CT scan may be normal in the initial stages. Early neurosurgical intervention is desirable to reduce mortality and morbidity in this condition.
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