Vaginal delivery in a patient with asymptomatic severe aortic stenosis: a case report

Heart disease complicates about 1-4% of all pregnancies of which valvular heart disease is the commonest cause. In developing countries, congenital heart diseases are commonly first detected during pregnancy. Most women do well during pregnancy but severe mitral stenosis or severe aortic stenosis are high-risk conditions that can cause significant morbidity and mortality. Unlike asymptomatic severe mitral stenosis, asymptomatic severe aortic stenosis is mWHO category 3. There is no consensus on the mode of delivery in patients with asymptomatic severe aortic stenosis. Here we describe a case of successful vaginal delivery in a woman with severe aortic stenosis. As the patient was asymptomatic and ejection fraction was preserved, a joint decision for vaginal delivery was taken along with the cardiology team. The patient was induced and delivered with operative vaginal delivery. This case shows that vaginal delivery could be a viable option in patients with asymptomatic severe aortic stenosis given continuous haemodynamic monitoring can be provided

Pregnancy in a patient with paroxysmal nocturnal hemoglobinuria

The occurrence of Paroxysmal Nocturnal Hemoglobinuria (PNH) during pregnancy is very rare. It can cause significant fetomaternal morbidity and mortality due to associated complement mediated hemolysis and/or thrombosis. We report a case of PNH in a pregnant lady who presented to our antenatal clinic at 10th weeks of gestation. Her pregnancy was managed with multiple blood transfusions and steroid administration.  During 3rd weeks postpartum period she developed sepsis with acute renal failure and posterior reversible encephalopathy syndrome requiring prolonged hospitalization. She was subsequently discharged from hospital in satisfactory condition

Association of human papilloma virus 16 infection and p53 polymorphism among tobacco using oral leukoplakia patients: A clinicopathologic and genotypic study

Background: Human papillomavirus (HPV) and p53 alterations are speculated to play a role in carcinogenesis. This study was carried out to find out the association of HPV and p53 with precancerous lesions of the oral cavity such as leukoplakia: The objective of this study was to find the association among human papilloma virus (HPV) 16 infections and p53 polymorphism in tobacco using the oral leukoplakia patients. Methods: A total of 91 oral leukoplakia patients and 100 controls were randomly selected from the out-patient department of a tertiary care dental hospital of North-east India. Blood samples were drawn incisional biopsy was performed from the lesion proper and the tissue was processed for histopathological grading. Cytological smears were taken from the lesional site of leukoplakia patients and buccal mucosa of controls. The rate of HPV infection and p53 polymorphism was detected with the help of polymerase chain reaction, gel electrophoresis and deoxyribonucleic acid sequencing. Results: The rate of HPV 16 infection was found significantly high in the oral leukoplakia patients. No particular p53 genotype at exon 4 of codon 72 was found to be associated with oral leukoplakia, but "C" allele (proline) at exon 4 of codon 72 was significantly raised in these patients. Conclusions: Oral leukoplakia, a well-known pre-cancerous lesion, has been shown to be associated with tobacco, but certain other factors like HPV infection and p53 polymorphism may play an important role in its development

A review of histopathological and immunohistochemical parameters in diagnosis of metastatic renal cell carcinoma with a case of gingival metastasis

The oral cavity constitutes a site of low prevalence for metastasis of malignant tumors. However, oral metastasis of a renal origin is relatively more common and represents 2% of all cancer deaths. Renal cancer may metastasize to any part of the body, with a 15% risk of metastasis to the head and neck regions, and pose one of the greatest diagnostic challenges in medical sciences. Approximately 25% of patients have a metastatic disease at initial assessment, which is often responsible for initiating the diagnosis in the first place. Here we present a review of literature of renal cell carcinoma along with a case of gingival metastasis

Detection of oral squamous cell carcinoma metastasis with cathepsin D: An immunohistochemical approach

Background: The lysosomal protease cathepsin D (CD) has been associated with tumor progression in malignant tumors including oral squamous cell carcinoma (OSCC). The purpose of this study was to find out any association between the CD and lymph node metastasis and to study the correlation of CD with various clinicopathological parameters to aid in assessment of its role as a prognostic indicator. Materials and Methods: Immunohistochemical staining was performed on 20 OSCC samples with polyclonal antibody against CD. Positive results indicative of the presence of CD were further analyzed to determine any correlation between the CD and other clinicopathological parameters. Pearson Chi-square analyses, Spearsman correlation coefficient, Mann-Whitney test, Kruskal Wallis test and student t test were used for statistical analysis (P < 0.05). Results: Patients with lymph node metastasis showed statistically significant increase in CD expression (P < 0.01). Increasing tumor size seemed to correlate with increased CD expression (P < 0.05). Conclusion: Based on its association with other clinicopathological variables, CD expression can be used for the assessment of patient survival in cases of OSCC

Statin Hepatotoxicity: Is it a Real Concern?

Statins are the most effective and widely used drugs for treating dyslipidemia, a major risk factor for coronary heart disease. These are one of the safest hypolipidemic drugs but many patients are advised to discontinue statins for the fear of hepatotoxicity. Despite a lack of evidence that statins cause liver diseases, many physicians are reluctant to start statins in patients with an out-of-range liver enzymes value and this reluctance to initiate or interrupt the therapy with statins leads to dyslipidemia and its grave consequences. Further, there are some reports showing an additional benefit of statins in reducing cardiovascular events in patients with abnormal liver function tests

Blue cures blue but be cautious

Methemoglobinemia is a disorder characterized by the presence of >1% methemoglobin (metHb) in the blood. Spontaneous formation of methemoglobin is normally counteracted by protective enzyme systems, for example, nicotinamide adenine dinucleotide phosphate (NADPH) methemoglobin reductase. Methemoglobinemia is treated with supplemental oxygen and methylene blue (1–2 mg/kg) administered slow intravenously, which acts by providing an artificial electron acceptor for NADPH methemoglobin reductase. But known or suspected glucose-6-phosphate dehydrogenase (G6PD) deficiency is a relative contraindication to the use of methylene blue because G6PD is the key enzyme in the formation of NADPH through pentose phosphate pathway and G6PD-deficient individuals generate insufficient NADPH to efficiently reduce methylene blue to leukomethylene blue, which is necessary for the activation of the NADPH-dependent methemoglobin reductase system. So, we should be careful using methylene blue in methemoglobinemia patient before G6PD levels

Factors affecting the outcome of pregnancy with rheumatic heart disease: an experience from low-middle income country

Studies on pregnancy with rheumatic heart disease (RHD), still common in the developing world, are relatively old and small. This retrospective study was conducted to study the outcome of pregnancy in women with RHD and factors associated with poor outcome. We studied 353 pregnancies in 273 women. In 35% of the patients, the diagnosis was first made during index pregnancy. Women with severe MS had lesser gestational age at delivery and birth weight than those with mild-to-moderate MS. Women with NYHA III-IV status delivered at lesser gestational age had lesser birth weight and had higher perinatal and maternal mortality than NYHA I-II status. Pregnancy outcome was better among women who underwent Balloon mitral valvotomy (BMV) when indicated than those who did not. Cardiac complications were higher in women with severe MS and poor NYHA status. Early booking is important for the optimal outcome. BMV is safe during pregnancy and should be done when necessary.Impact statement What is already known on this subject? Rheumatic heart disease continues to be the major cause of maternal morbidity and mortality in developing countries. Most of the recent studies discuss pregnancy with heart disease as a whole with RHD being a part. What do the results of this study add? A large number of women in developing countries conceive with unknown underlying heart disease. Late access to antenatal care is associated with poor outcome. Cardiac and obstetric complications are significantly higher in women with severe mitral stenosis and poor NYHA functional status. Balloon mitral valvotomy (BMV) during pregnancy is safe and technically feasible. BMV averts major complications that may occur due to severe disease. Patients with RHD can undergo labour and vaginal delivery under vigilant monitoring. What are the implications for clinical practice? Thorough clinical examination by the clinician at initial visit is important to detect unknown heart disease. Symptoms pointing towards underlying heart disease should prompt evaluation. This study provides evidence for population-based screening for heart disease in women. Optimal management of compensated mitral stenosis requires weighing the risks and benefits of pharmacological therapy versus BMV in the context of maternal condition. BMV should be performed when necessary

Management of Pseudohypoparathyroidism Type 1a during Pregnancy and Labor: A Case Report

Pseudohypoparathyroidism is rare during pregnancy and poses multiple challenges related to its diagnosis and management during pregnancy. We hereby report a case of a young woman who was diagnosed to have type 1a pseudohypoparathyroidism. She was managed by multidisciplinary team and had good maternal and perinatal outcome. Management-related issues are discussed here in detail

Study of antinociceptive activity of SSRI (fluoxetine and escitalopram) and atypical antidepressants (venlafaxine and mirtazepine) and their interaction with morphine and naloxone in mice

Objective : to study the probable site of antinociceptive action of SSRI (fluoxetine, escitalopram) and atypical antidepressants (mirtazapine, venlafaxine) and their interaction with morphine and naloxone. Materials and Methods : the study was conducted on albino mice (25-35 grams) of either sex. Different doses of morphine (0.5 and 1 mg/kg), fluoxetine (2, 5 and 10 mg/kg), venlafaxine (30, 40 and 50 mg/kg), mirtazapine (3, 5 and 7 mg/kg) and escitalopram (2.5, 5 and 10 mg/kg) were administered subcutaneously to obtain their subanalgesic doses using tail flick analgesiometer. Tail flick latencies were obtained at 15, 30, 60 and 120 min. after drug administration. Naloxone (1 mg/kg) was administered 10 minutes prior to test drug for testing antagonism. Observations : fluoxetine (5 and 10 mg/kg), mirtazapine (5 and 7 mg/kg) and venlafaxine (40 and 50 mg/kg) were found to have antinociceptive activity but not at lower doses. Escitalopram failed to show any antinociceptive activity at any of the doses used. The antinociceptive effect of all the drugs was antagonized by naloxone (1 mg/kg). Further, subanalgesic doses of fluoxetine, mirtazapine and venlafaxine showed analgesic activity with suboptimal dose of morphine (0.5 mg/kg). Result and conclusion : fluoxetine, mirtazapine and venlafaxine have antinociceptive activity whereas escitalopram doesn′t; their site of action seems to be the same as that of opioid analgesics (′mue′ receptors). However, other pathways (cholinergic, histaminic, noradrenergic, GABAergic) may be involved in mediation of their analgesic activity, deserving further elucidation. Results apparently show that these drugs may be useful in the management of pain as monotherapy or in combination with other opioids