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Guntupalli K.K.,Baylor College of Medicine | Hall N.,Baylor College of Medicine | Karnad D.R.,Jupiter Hospital | Bandi V.,Baylor College of Medicine | Belfort M.,Baylor College of Medicine
Chest | Year: 2015

Managing critically ill obstetric patients in the ICU is a challenge because of their altered physiology, different normal ranges for laboratory and clinical parameters in pregnancy, and potentially harmful effects of drugs and interventions on the fetus. About 200 to 700 women per 100,000 deliveries require ICU admission. A systematic five-step approach is recommended to enhance maternal and fetal outcomes: (1) differentiate between medical and obstetric disorders with similar manifestations, (2) identify and treat organ dysfunction, (3) assess maternal and fetal risk from continuing pregnancy and decide if delivery/termination of pregnancy will improve outcome, (4) choose an appropriate mode of delivery if necessary, and (5) optimize organ functions for safe delivery. A multidisciplinary team including the intensivist, obstetrician, maternal-fetal medicine specialist, anesthesiologist, neonatologist, nursing specialist, and transfusion medicine expert is key to optimize outcomes. Severe preeclampsia and its complications, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, and amniotic fluid embolism, which cause significant organ failure, are reviewed. Obstetric conditions that were not so common in the past are increasingly seen in the ICU. Thrombotic thrombocytopenic purpura of pregnancy is being diagnosed more frequently. Massive hemorrhage from adherent placenta is increasing because of the large number of pregnant women with scars from previous cesarean section. With more complex fetal surgical interventions being performed for congenital disorders, maternal complications are increasing. Ovarian hyperstimulation syndrome is also becoming common because of treatment of infertility with assisted reproduction techniques. Part II will deal with common medical disorders and their management in critically ill pregnant women. © 2015 American College of Chest Physicians.

Guntupalli K.K.,Section of Pulmonary | Karnad D.R.,Jupiter Hospital | Bandi V.,Section of Pulmonary | Belfort M.,Baylor College of Medicine
Chest | Year: 2015

The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly aff ect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specifi city in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confi ned to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specifi c adjustments in the management of these disorders. © 2015 American College of Chest Physicians.

Rokade M.L.,Jupiter Hospital
Journal of Medical Ultrasound | Year: 2013

Background: The urinary bladder has many inherent characteristics that make it an ideal structure for evaluating with three-dimensional (3D) volume ultrasound (US). The purpose of this study was to evaluate the application of 3D sonography in assessing bladder pathologies. Materials and methods: One hundred patients were evaluated in this study. The cases were taken from the pool referred for the evaluation of the renal system (kidney, ureter, and bladder), abbreviated as US KUB at our hospital. The examination was performed with the bladder filled up to 250-350ml, or whenever adequate distension was noted with wide separation of the bladder walls. Routine (two-dimensional) 2D scanning was followed with the acquisition of 3D volume using abdominal and endocavitary probes. Results: Application of surface rendering algorithm on obtained 3D data sets yielded near cystoscopy-like images of the urinary bladder. The anatomy of the trigonal region of the bladder and the ureteric orifices was obtained in detail. Various bladder pathologies, notably bladder mass, diverticuli and ectopic ureteric openings, were noted. Conclusion: 3D virtual cystoscopy is a promising technique for evaluating bladder pathologies. Its multiplanar capabilities and surface rendering capabilities are helpful for further characterizing the lesions seen on 2D US. It can serve as a good road map prior to cystoscopy. © 2013.

Rokade M.L.,Jupiter Hospital
Journal of Medical Ultrasound | Year: 2011

Ambiguous genitalia is a medical term for rare condition in which the newborn's external genitalia do not conform to either male or female type. The condition of ambiguous genitalia has serious psycho-social concerns and is usually followed-up with a multitude of complex tests for identifying the gender and the cause of the anomaly. Three cases of ambiguous genitalia are reported here where ultrasound helped to elucidate the probable cause and to direct further appropriate tests. © 2011.

Puri V.,KEM Hospital | Venkateshwaran N.,Jupiter Hospital | Khare N.,KEM Hospital
Indian Journal of Plastic Surgery | Year: 2012

The management of patients with trophic ulcers and their consequences is difficult not only because it is a recurrent and recalcitrant problem but also because the pathogenesis of the ulcer maybe different in each case. Methodically and systematically evaluating and ruling out concomitant pathologies helps to address each patient's specific needs and hence bring down devastating complications like amputation. With incidence of diabetes being high in our country, and leprosy being endemic too the consequences of neuropathy and angiopathy are faced by most wound care specialists. This article presents a review of current English literature available on this subject. The search words were entered in PubMed central and appropriate abstracts reviewed. Relevant full text articles were retrieved and perused. Cross references from these articles were also reviewed. Based on these articles and the authors' experiences algorithms for management have been presented to facilitate easier understanding. It is hoped that the information presented in this article will help in management of this recalcitrant problem.

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