presentation on obgy anemia in mbbs.pptx

Here’s a summary of Nephrotic Syndrome (from standard medical sources like Harrison’s, Nelson’s, and Davidson’s):


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Nephrotic Syndrome – Summary

Definition:
Nephrotic syndrome is a clinical complex characterized by heavy proteinuria (>3.5 g/day in adults or >40 mg/m²/hr in children), leading to hypoalbuminemia, edema, hyperlipidemia, and lipiduria.


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Pathophysiology:

Damage to glomerular filtration barrier (podocytes, basement membrane, endothelium) → increased permeability to plasma proteins.

Loss of albumin in urine → decreased plasma oncotic pressure → edema.

Liver compensates by increasing lipoprotein synthesis → hyperlipidemia.

Loss of regulatory proteins (antithrombin III, IgG, etc.) → ↑ risk of thrombosis and infections.



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Etiology:

1. Primary (Idiopathic) Glomerular Diseases:

Minimal change disease (common in children)

Focal segmental glomerulosclerosis (FSGS)

Membranous nephropathy

Membranoproliferative GN


2. Secondary Causes:

Diabetes mellitus (diabetic nephropathy)

Systemic lupus erythematosus (SLE)

Amyloidosis

Infections (Hepatitis B, C, HIV, malaria)

Drugs (NSAIDs, gold, penicillamine)



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Clinical Features:

Generalized edema (starting as periorbital, then pitting edema, ascites, pleural effusion)

Frothy urine (due to proteinuria)

Weight gain

Fatigue, pallor

Complications:

Infection (due to loss of IgG, complement)

Thrombosis (renal vein, DVT, PE)

Hypovolemia, acute kidney injury




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Investigations:

Urinalysis: Proteinuria, lipiduria (fat bodies, Maltese crosses)

24-hour urine protein / Spot protein:creatinine ratio

Serum albumin: ↓

Serum cholesterol & triglycerides: ↑

Renal function tests: May be normal or mildly abnormal

Renal biopsy: To determine underlying cause (except in typical minimal change disease in children)



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Management:

1. General Measures:

Salt restriction

Diuretics (for edema)

Adequate protein intake (not excessive)

Control hyperlipidemia (statins)

Anticoagulation if thrombosis risk high

Vaccination (pneumococcal, influenza)


2. Specific Treatment:

Minimal Change Disease: Corticosteroids (Prednisolone)

FSGS, Membranous GN: Steroids ± immunosuppressants (cyclophosphamide, cyclosporine, tacrolimus)

Secondary causes: Treat underlying disease (e.g., control diabetes, treat infection, stop offending drug)



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Prognosis:

Children: Usually good (especially minimal change disease).

Adults: Depends on cause — FSGS and membranous nephropathy may progress to chronic kidney disease.



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Would you like me to make this into a chart or table format (easy for revision or presentation)?

1. ANEMIA IN PREGNANCY A PRESENTATION BY BATCH F (126-150)

2. DEFINITIONS WHO: Hb<11g/dL or Hct<33% According to WHO def 50% of pregnant women are anemic in India. CDC: T1 and T3- Hb<11g/dL or Hct<33% T2- Hb<10.5g/dL or Hct<32% According to CDC def, 60% of Indian women are anemic at some point during their pregnancy out of which 40% are anemic throughout pregnancy . Anemia is the most common hematological disorder in pregnancy responsiblw for 20% of maternal deaths in lower and middle income countries.

3. CLASSIFICATION ETIOLOGIC PHYSIOLOGICAL ANEMIA OF PREGNANCY DEFICIENCY ANEMIA IRON (most common) VIT B12 FOLIC ACID HEMORRHAGIC ACUTE- APH CHRONIC- HOOKWORM HB-PATHY THALESSEMIA SICKLE CELL DISEASE CHRONIC DISEASES TB MALARIA MALIGNANCIES LEUKEMIA LYMPHOMA HEMOLYSIS SLE HELLP AUTOIMMUNE G6PD DEF

4. PHYSIOLOGICAL ANEMIA: CAUSES Increased maternal plasma volume by 40-50% and RBC vol by 20% causing relative hemodilution . Increased demand of iron during pregnancy. Additional iron requirement in pregnancy=1000mg out of which 300mg is consumed by fetus and placenta and 700mg by mother. Reduced sr iron and increased TIBC. Fall in Hb and Hct values due to hemodilution .

5. IRON DEFICIENCY ANEMIA

6. IRON DEFECIENCY ANEMIA: CAUSES BEFORE PREGNANCY : Faulty dietary habits Faulty absorption mechanism Iron loss : repeated pregnancies at short interval, excessive blood loss during menstruation DURING PREGNANCY : Increased iron demand Diminished intake Diminished absorption Infections Pre pregnant health conditions (already anemic )

7. CLINICAL FEATURES Mostly asymptomatic with accidental diagnosis. Easy fatigueability . Anorexia Indigestion Palpiotations Dyspnea Giddiness Pallor Glossitis, stomatitis, angular cheilitis Brittle, fragile nails Choilonychia Swelling of legs Systolic murmur Crepitations at the base of lungs

8. INVESTIGATIONS TO NOTE THE DEGREE OF ANEMIA Hb<10g% Total RBCs< 4 mil/cu mm PCV< 30% TO ASCERTAIN THE TYPE OF ANEMIA PBS- microcytic hypochromic with aniso and poikilocytosis Hematological indices- MCV< 75 fL , MCHC< 30% (most sensitive index for IDA) TO CONFIRM ETIOLOGY Stool examination- hookworm Urine examination- UTI GRADES OF ANEMIA NORMAL >11g% MILD 10-11g% MODERATE 7-10g% SEVERE 4-7g% VERY SEVERE <4g%

9. COMPLICATIONS ANTENATAL Pre eclampsia Infections CCF Plummer Vinson Syndrome Preterm labor and ANTENATAL INTRAPARTUM POSTPARTUM PRE ECLAMPSIA PPH PUERPERAL SEPSIS INFECTIONS CCF SUBINVOLUTION CCF SHOCK POOR LACTATION PLUMMER VINSON SYNDROME UTERINE INERTIA DVT, PE PREMATURITY PERINATAL LOSS POOR WOUND HEALING IUGR PP DEPRESSION

10. TREATMENT: PROPHYLAXIS Spacing of births: minimum interval between pregnancies = 2 years (ideally >3 years) 1 IFA pill (60 mg elemental iron + 500 mcg FA) per week to women of reproductive age group (ANEMIA MUKT BHARAT) Hookworm eradiction by Tab Albendazole 400 mg once in T2 1 IFA/day in T2 and T3, continued for 180 days post partum Oral preparations of iron: IRON SALT AMOUNT (mg) ELEMENTAL IRON (mg) FE FUMARATE 200 65 FE GLUCONATE 300 35 FE SULPHATE 300 60 FE SULPHATE 200 65

11. ORAL IRON THERAPY 2 IFA/day is the starting dose Rate of improvement = 0.7g% per week Reduce dose to 1 IFA/day when Hb >11g% Side effects: Constipation, black stools Diarrhoea Nausea, vomiting Epigastric pain Metallic taste Causes of failure of therapy: Wrong diagnosis of anemia GI disorder causing improper absorption Non compliant patient Infections Coexisting FA def C/I to oral therapy: Intolerance (prominent S/E) Severe anemia Advanced pregnancy

12. PARENTERAL IRON THERAPY Indications: Non compliant patient Intolerance Mild-mod anemia in GA >34 wk Severe anemia in GA <34 wk C/I: Hypersensitivity to parenteral iron Dose calculation (GANZONI FORMULA): Total iron reqd (mg) = [2.4 * wt in kg * Hb deficit] +500 Hb deficit = 11- patient Hb Drugs used: Inj iron sucrose 200 mg in 200 mL NS iv over 30 min (20mg iron/mL), 2-3 times a week Inj iron carboxymaltose 1000 mg in 250 mL NS iv over 15 min, once a week Advantages of iv therapy over im : Not painful Early discharge cheaper

13. ROLE OF BLOOD TRANSFUSION Indications: Severe anemia in GA> 34 wk Hb <5g% in any T Hb <10g% in labour Allergy to parenteral iron therpy CCF ( BT+furosemide ) Hemorrhage Thalessemia major Sickle cell disease 80-100 mL of PCV to be given at a time BT should not be repeated within 24 hrs Rate of improvement: rise in Hb by 1g% per PCV transfused Precautions: im Phenergan 25 mg (anti-H) im furosemide 20 mg 20 min before BT Monitor for premature labour

14. LABOUR MANAGEMENT Left lateral or propped up position Epidural if needed O2 therapy with target SpO2 >95% Iv fluid restriction <125 mL/hr Minimal PV examinations Prophylactic forcep (>ventouse) delivery to shorten second stage AMTSL Blood loss compensated by BT + furosemide 20 mg iv Prophylactic antibiotics Hematinics contd in post partum period Contraceptive and PP counselling

15. MEGALOBLASTIC ANEMIA

16. MEGALOBLASTIC ANEMIA Occurs due to deficiency of vit B12 or folate or both. In pregnancy FA def is more common than B12 def RDA of B12 during pregnancy= 3 mcg (N=2 mcg) RDA of FA during pregnancy= 200 mcg B12 deficiency results in impaired synthesis of both RNA and DNA FA deficiency causes impaired synthesis of DNA only Incidence = 0.5-3% More common in multiparae (5x) and in multifetal pregnancies (8x) FA deficiency causes NTD, cleft lip/palate and prematurity in fetus .

17. CAUSES CAUSES OF B12 DEF CAUSES OF FOLIC ACID DEF STRICT VEG DIET INADEQUATE INTAKE GASRTRITIS/ H. PYLORI RAISED DEMAND IN PREGNANCY GASTRECTOMY/ BARIATRIC SURGERY MALABSORPTION SYNDROME CROHN’S DISEASE INFECTIONS PERNICIOUS ANEMIA ANTI EPILEPTIC DRUGS MALABSORPTION SYNDROME LIVER DISORDERS DRUGS- PPI, METFORMIN, COC PILLS IRON,VIT C DEFICIENCY HYPERHOMOCYSTEINEMIA

18. CLINICAL FEATURES Manifested in late T3 or early puerperium Anorexia Vomiting Diarrhoea Fever Pallor Glossitis Ecchymosis Enlarged liver and spleen (though not palpable due to gravid uterus) Pre eclampsia

19. INVESTIGATIONS Hb <10g% PBS: any 2 of the following 5 Hypersegmented neutrophils Macrocytosis and anisocytosis Giant neutrophils Megaloblasts Howell jolly bodies (nuclear remnants) MCV >100fL, MCH >33 pg , MCHC normal Leukopenia, thrombocytopenia Sr B12 <90 pg /mL (N= 300 pg /mL) TO DIFFERENTIATE BETWEEN FOLATE AND B12 DEFICIENCY : FA def: raised homocysteine and normal methylmalonate 2. B12 def: both homocysteine and methylmalonate are raised

20. TREATMENT All women of reproductive age should be given 400 mcg FA daily. 4000 mcg FA daily should be given in following conditions: Patient on anti convulsant therapy Previous pregnancies with NTD Hb- pathy Fam h/o congenital heart diseases Therapy should be started 3 months preconception till completion of T1. 1 mg FA daily with iron (2 IFA tabs) Inj Vit B12 im 100 mcg on alternate days if response to FA therapy is not adequate Tab Ascorbic acid 100 mg tds imcreases FA activity Nutritious diet is advised Respoinse is evidenced by: sense of well being Increased appetite Increased cell counts Rise in Hb

21. HEMOGLOBINOPATHIES

22. HEMOGLOBINOPATHIES Hemoglobinopathies are inherited specific biochemical disorders [quantity or quality] within the polypeptide chain of globin fraction. SICKLE CELL ANEMIA : inherited structural abnormallity THALASSEMIA : Inherited defect in synthesis and production of globin

23. SICKLE CELL HEMOGLOBINOPATHIES Autosomal recessive disease. It is caused by point mutation in beta globin gene on chromosome 11. Substitution of valine for glutamic acid at position 6 th of beta chain Sickle cell trait : Hb –AS it is a carrier state. Sickle cell disease : [Hb-SS] Homozygous sickle cell disease Sickle cell beta thalassemia : 1 beta chain gene carries sickle cell mutation , other chain is deleted.

24. Pathophysiology Hb S In oxygenated state behave normally Precipitating factor : Infection deoxygenated acidosis state dehydration hypoxia and cooling aggregates , polymerizes and distortred cell to sickle Sickle shaped cell block microcirculation [Sickling phenomenon] Diagnosis : 1. Refractory hypochromic anemia 2. Sickling test 3. persistent reticulocytosis 4. high fasting serum iron level 5.electrophoresis

25. . Effect on pregnancy : Increase incidence of 1. miscarriage [25%] 4.Preeclaimpsia 2. Prematurity and IUGR 5.PPH 3.Stillbirth 6. Infection Effect on disease : Hemolytic crisis Painful ( vasoocclusive ) crisis MANAGEMENT: 1.Preconceptional counselling 2. During pregnancy - A] careful antenatal supervision B] Prophylactically Fa 5mg tab daily C] exchange blood transfusion D] penicillin prophylaxis for infection E] Hydroxyurea ( increases Hb F) F] Thromboprophylaxis with LMWH

26. THALASSEMIA SYNDROME Inherited quantitative biochemical disorder 2 types : 1. alpha thalassemia 2. beta thalassemia PATHOLOGY: reduced rate of globin chain synthesis red cell with inadequate Hb content deficient erythropoiesis , reduced RBC life span, hemolysis Ultimately Anemia

27. Alpha Thalassemia Alpha chain production controlled by 4 gene ( chr no. 16) 1. mutation in 1 gene – silent carrier 2. mutation in 2 gene – alpha thalassemia minor 3. mutation in 3gene – Hb H Disease 4. mutation in all 4 gene – alpha thalassemia major parenteral diagnosis : CMVS or Amniocentesis Treatment : IFA supplementation blood transfusion if indicated

28. Beta Thalassemia Beta chain production controlled by 2 gene (chr no. 11) Beta thalassemia major : cooleys anemia - progressive hepatosplenomegaly - impaired growth,anemia,ccf,intercurrent infection Beta thalassemia minor : Hb A2 [alpha 2 delta 2] Hematological findings : 1. low MCV,MCH Normal MCHC 2. Sr Fe and TIBC –normal/ elevated 3. Hb electrophoresis- raised Hb A2 4. Sr. bilirubin raised 5. mild anemia

29. Preconceptional counselling and treatment Both parents advised for Hb electrophoresis Preimplantation blastomere biopsy and DNA study (in IVF) Iron chelation therapy with Desferroxamine Blood transfusion In thalassemia major oral and IV iron therapy is contraindicated

30. QUESTIONS

31. Which is not a cause of physiological anemia in pregnancy? Increased plasma Decreased RBCs Increased iron demand Vegeterian diet

32. b) Decreased RBCs Plasma volume increases by 50% while RBC volume increases by 20% causing dilutional anemia

33. Which is not an intravenous iron preparation? Iron sucrose Iron isomaltose Iron sulphate Iron carboxymaltose

34. c) Iron sulphate Iron sulphate is the most commonly used oral preparation of iron containing 60 mg elemental iron in 300 mg dose

35. 20 y/o primigravida with 28 weeks of amenorrhea presents with pallor and fatigue. PBS picture is microcytic hypochromic with reduced sr iron and raised TIBC. Hb= 9g%. How will you correct the anemia ? Oral iron therapy Parenteral iron therapy PCV transfusion Patient cannot be saved

36. a) Oral iron therapy Patient is in early T3 with moderate anemia (7-10g%). Monotherapy of choice is oral IFA tab 2-3 times a day till Hb becomes 11g% Remember polytherapy (oral + parenteral) in case of iron therapy is to be avoided.

37. Which of these is raised in serum in folate deficiency? Methylmalonate Homocysteine Both None

38. b) Homocysteine B12 def = raised methylmalonate + raised homocysteine FA def = raised homocysteine (+ raised urinary excretion of FIGLU)

39. A 24 y/o woman k/c/o epilepsy disorder is on valproate and wishes to conceive. What advise will you give? Continue valproate with 0.4 mg FA daily for 3 months Switch to lamotrigine with 0.4 mg FA daily for 3 months Continue valproate with 4 mg FA daily for 3 months Switch to lamotrigine with 4 mg FA daily for 3 months

40. d) Switch to lamotrigine with 4 mg FA daily for 3 months AEDs safe in pregnancy = LAMOTRIGINE, LEVETIRACETAM Valproate causes NTD and cardiac anomalies. Recommended dose of FA in patient on valproate is 4 mg/day for 3 months pre conception. IF THE PATIENT IS PREGNANT AND ON VALPROATE, DO NOT SWITCH

41. MENTZER INDEX is used to differentiate between? Microcytic and macrocytic anemias Folic acid and vit B12 def anemias IDA and thalassemia Thalassemia and sickle cell anemia

42. c) IDA and thalessemias Mentzer index = MCV/RBC count If >13 then IDA If <13 then thalessemia

43. When is deworming day celebrated in India? 21 March and 21 September 17 January and 17 July 12 March and 12 September 10 February and 10 August

44. d) 10 feb and 10 aug Tab Albendazole 400 mg once is provided to all school going children and adolescents to eradicate anemia due to hookworm infestation

45. What is to be avoided during labour in an anemic patient? Propped up position Epidural anasthesia Large amounts of IV fluids Inj oxytocin 10 IU im after delivery of baby

46. c) Large amounts of IV fluids IV fluids are restricted to <125 mL/hr. oral fluids can be given as and when required.

47. THANK YOU