Cardiac Arrest In Pregnancy

Cardiac Arrest in Pregnancy Dr .S. HEM CHANDER Dept. Accident & Emergency Medicine Sri Ramachandra Medical College & Research Institute (DU) Porur, Chennai

Two for One Caring for the Pregnant Trauma Patient

Classification

Two for One Caring for the Pregnant Trauma Patient

Contd.., Nematodes or roundworms  Intestinal nematodes – enterobius vermicularis,ascaris lumbricoides,trichuris trichiura,necator americanus,ancylostoma duodenale,strongyloides stercolis  Tissue dwelling nematodes – wuchereria bancrofti,brugia malayi,loa loa,dracunculus medinensis

Contd..,  Zoonotic nematodes – toxocara

canis,trichinella spiralis

Trematode infections  Flukes are flat ,oval shaped worms with

suckers  Adult worms produce eggs that are passed from body in faeces ,urine or sputum  Disease is caused by inflammatory response either to worms or to eggs in tissues

Schistosomiasis (bilharziasis)  Mode of transmission – ovum passed in urine

or faeces gains access to fresh water ciliated miracidium is liberated and enters intermediate host snail and multiplies fork tailed cercariae are liberated in to water infects humans

Contd..,  Cercariae can penetrate skin or mucous

membrane of mouth  Transform in to schistosomulae and moult as they pass thro lungs and carried by blood to liver and to portal vein where they mature  Male worm -20cm in length ,enfolds the female longitudinally

Pathology  Cercarial penetration – (days) papular

dermatitis at site of penetration  Larval migration &maturation (weeks)pneumonitis ,myositis,hepatitis,fever,serum sickness,eosinophilia,seroconversion  Early egg deposition (months)cystitis,hematuria,ectopic granulomatous lesions,immune complexglomerulonephritis

Contd..,  Colitis, granulomatous hepatitis,acute portal

hypertension  Late egg deposition(years)- fibrosis &calcification of ureters,bladders,hydronephrosis,pul.granulo mas,pul.hypertension,colonic polyposis&strictures,periportal fibrosis

Clinical features  Itching at the site of penetration (1-2days)  After 3-5

wks.urticaria,eosinophilia,fever,muscle aches,cough,sweating  These allergic symptoms are known as katayama syndrome

Contd..,  Painless hematuria,haemospermia,papillomata of

vulva  S.japonicum may cause epilepsy ,hemiplegia,blindness,paraplegia  Investigations  Microscopic examination of urine,stools  Cystoscopy reveals sandy patches,bleeding mucosa

Management  The object of treatment is to kill adults

&stop egg laying  Praziquantel 40mg/kg p.o. once  Oxamniquine 15 mg/kg p.o.12hrly for 2 days  Metrifonate 7.5mg/kg p.o.q 2wks.thrice

Paragonimiasis (endemic hemoptysis)  Adult fluke measures 10*6 mm ,live in

small nests in lung  Sputum contains ova which may be swallowed or expectorated passed in faeces miracidia emerge in water 1st intermediate host snail 2nd intermediate host crabs or cray fish to definitive host humans

Pathology  Adults lie in cysts ,up to 1cm in diameter

situated chiefly in lung ,containing reddish brown fluid  In heavy infections cysts may also present in pleural /peritoneal cavities ,in brain,muscles and skin

Clinical features  Fever ,cough & expectoration of

brown/black sputum  Occasionally bouts of frank hemoptysis with severe pain in chest  If parasites lodge in abd.there may be symptoms of enteritis/hepatitis

Contd..,  In abd. wall it produces sinuses which

discharge thro skin  Cysts in CNS cause signs of cerebral irritation,encephalitis or myelitis

Investigations  Microscopic examination of sputum ,faeces  Radiological features of affected lung are

variable  Extra pulmonary lesions are diagnosed by biopsy

Management  Praziquantel 25mg/kg p.o. 12hrly for 2 days  Localised lesions may be treated surgically

Liver flukes  Mode of spread – ova in faeces ,water ,to

humans  1st intermediate host – dogs,cats,sheep,cattle  2nd intermediate host – fresh water fish  Pathology – cholangitis, abscesses,biliary ca,toxaemia,eosinophilia

Contd..,  Symptoms – recurrent jaundice,fever,tender

liver  Diagnosis – ova in stool or duodenal aspirate  Treatment – praziquantel 25mg/kg 8hrly for 2days

Cestode infections (tape worms)  Cestodes are ribbon shaped worms which

inhabit intestinal tract  They absorb nutrients thro tegumental surface  The head /scolex has suckers for attachment  Humans acquire tapeworm by eating under cooked beef ,pork or fish

Taenia solium &cysticercosis  The larvae liberated from eggs in stomach

penetrate intestinal mucosa and are carried to many parts of body  They develop &form cysticerci 0.5-1cm cysts that contain the head of a young worm  Common locations are subcutaneous tissue,skeletal muscle,&brain

Clinical features  When superficially placed cysts can be

palpated under skin/mucosa as pea like ovoid bodies  Heavy brain infections may cause features of encephalitis  Epilepsy,personality changes,staggering gait ,signs of int.hydrocephalus are common features

Investigations  Calcified cysts can be recognised

radiologically  C.T. brain,M.R.I.,  Fluorescent antibody test,ELISA

Management  Praziquantel 50mg/kg tid for 10 days or

albendazole 15mg/kg od for 8 days +  Prednisolone 10 mg q8hrs for 14 days  Antiepileptic drugs

Echinococcus granulosus & hydatid disease  Dogs ,cattle,sheep are definitive host of

these tiny tape worms  The embryo liberated from ovum in small intestine spread thro blood stream to liver  The resultant cyst may calcify or rupture giving rise to multiple cysts

Clinical features  The rt. Lobe of liver is invaded & contain a

single cyst  Dull ache in rt.hypochondrium  Hydatid thrill  Cyst may also found in long bone ,brain,or else where

Investigation  Casonis intra dermal test  Radiological & ultra sound investigations  Complement fixation  ELISA

Management  Hydatid cyst should be excised whereever

possible  Care to be taken to avoid spillage & cavities sterilised with 0.5% silver nitrate/ 2.7% NaCl  Albendazole 400 mg 12 hrly for 3 months for inoperable cases  Praziquantel 20mg/kg 12hrly for 14 days

Nematodes infection  Divided in to 3 groups

Intestinal nematodes  These worms live in lumen of gut and do not involve tissues  They cause a syndrome of fever ,cough,and eosinophilia during the stage of larval invasion

Contd..,  Tissue dwelling human nematodes  These are the filarial &guinea worms  Complex life cycle with an intermediate

host  It provokes massive eosinophilia

Contd..,  Zoonotic nematodes  Nematodes that normally infect other

animals may cause serious incidental infections in humans  They provoke severe inflammatory reactions characterised by eosinophilic granulomas

Enterobius vermicularis (threadworm)  Affects children more commonly  Male worm – 2-5mm long ,female 8-13 mm  After the ova are swallowed development

takes place in small intestine but adult worms are found in colon

Clinical features  The gravid female worms lay eggs around

anus and causes intense itching especially at night  In females genitalia may be involved  The adult worms may be seen moving on the stools

Investigations  Ova are detected by applying adhesive

surface of cellophane tape to perianal skin in morning  This is then examined on a glass slide under the microscope  A perianal swab moistened with saline is an alternative method

Management  Single dose of mebendazole 100mg or

pyrantel pamoate 10mg/kg or piperazine 4g  May be repeated after 2 wks to control auto re infection

Ascaris lumbricoides(round worm)  Pale yellow worm 20-35 cm long  The infected mature ova hatch in duodenum

&larvae migrate thro the lungs ascend the bronchial tree & are swallowed  They mature in small intestine  In heavy infections larvae in lung may cause pneumonitis & eosinophilia

Clinical features  Abd.discomfort ,colic  Vomiting ,loose stools  A tangled mass of worms may cause

int.obstruction  Other complications are blockage of bile or pancreatic duct and obst. Of appendix

Investigations  Microscopic examination of ova in faeces  Occasionally worms are demonstrated

radiographically by barium examination

Management  Mebendazole 100mg 12 hrly for 3 days  Or piperazine 4g as a single dose  Surgery required if obst. occurs

Trichuris trichiura (whipworm)  Due to ingestion of earth or food

contaminated with ova  Adult worm is 3-5 cm long and has a coiled anterior end resembling a whip  It inhabits caecum,lower ileum,appendix,colon and anal canal

Contd..,  Intense infections in children cause

persistent diarrhoea ,rectal prolapse,and stunting  Diagnosis by identifying ova in faeces  Treatment with mebendazole 100mg 12 hrly for 3-5 days or a single dose of oxantel pamoate 10mg/kg

Ancylostomiasis (hook worm)  Caused by parasitisation of small intestine

with ancylostoma duodenale or necator americanus  Greyish white nematode 1cm long which live in large numbers in duodenum and upper jejunum

Pathology  The larvae cause allergic inflammation at the site of

entry thro skin  In heavy infection – pul.eosinophilia  The worms attach themselves to mucosa of small intestine by their buccal capsule and with draw blood

The mean daily loss of blood from

one a.duodenale is 0.15ml and for n.americanus 0.03ml

Clinical features  Localised dermatitis at the site of infection  Paraoxysmal cough with hemoptysis  Vomiting,epigastric pain,loose stools  Anaemia

 Investigations – microscopic examination

of stools for ova &occult blood  Treatment – mebendazole 100mg bd for 3 days  Oral iron for anaemia

Filariasis  W.bancrofti is conveyed to humans by bite

of infected mosquitoes  Females produce micro filariae which at night circulate in peripheral blood  Causes lymphangitis, lymph oedema, rupture leads to cellulitis, fibrosis,&elephantiasis

Contd..,  Loclised pain &tenderness ,erythema,

epididymitis,orchitis,chyluria, chylous effusion  Tropical pul. Eosinophilia  Diagnosis – examination of wet blood film /microfiltration of blood,serology,ELISA  Treatment – DEC 9-12 mg/kg tid for 14 days