#gestational hypertension

[mcatmemoranda]

I have a pt who came in from clinic with elevated BPs at 35 weeks. If BPs are elevated above 140/90 on 2 separate occasions at least 4 hours apart at greater than 20 weeks gestation, it’s gestational HTN.

Once you get to that point, you check urine protein to creatinine ratio to see if the pt meets criteria for preeclampsia. So if the urine protein:creatinine (the OBs keep calling it “P to C”) is greater than or equal to 0.3, then the pt meets criteria for preeclampsia.

We talked to the pt about giving betamethasone to help with fetal lung maturity. You give 12 mg IM once and then a second dose 24 hours later (alternative dosing is 6 mg q12 for a total of 24 mg over the course of 2 days). It takes 24 hours after the second dose of betamethasone for it to provide maximum benefits to the fetus. So you have to note whether the pt is “beta complete,” meaning that it was at least 24 hours after the second dose before you started induction of labor. For women farther along in their pregnancy, this isn’t as important as it is for women earlier on in their pregnancy—so at 35 weeks, if you really needed to deliver before beta complete, the baby would have better outcome than a a 24 weeker, who you’d want to wait as long as possible to get to beta complete before inducing.

For pts with preeclampsia without any severe features, you should deliver at 37 weeks. If severe features, deliver at 34 weeks.

[wellhealthhub]

Exploring the Intricacies of Type 4 Diabetes: Gestational Diabetes Mellitus

Greetings, esteemed readers, and welcome to this all-encompassing, highly detailed guide centered on the elucidation of Type 4 Diabetes, an intriguing and somewhat less ubiquitous entity compared to its better-known counterparts, Type 1 and Type 2 Diabetes. Our paramount objective within the confines of this article is to embark on a comprehensive exploration, traversing the labyrinthine…

[ginontherox]

Pregnancy Rox: Facing Reality

First, let me take the time to wish all mothers a very happy & blessed Mother’s Day! My challenges with my current pregnancy began when I was about 4-5 months gestation. My first diagnosis was gestational diabetes. Naturally I became anxious and nervous, however my Ob/Gyn was very thorough and detailed so we began the process of monitoring my sugar levels 4 times a day everyday and I was…

[thisisthevoice]

alsoooo even in my own cohort i know theres at least one person whos pro-life and, last i knew, wanted to go into labor & delivery. i mean if youre a fucking nurse you shouldnt be "pro-life" (pro forced birth, anti maternal health) but im fucking scared for her patients if she goes down that route

[melted-heart-of-ice]

Reblogging to add pre-eclampsia and hyperemesis gravidarum

wild how like PCOS, endometriosis, vaginismus & hell, even frequent yeast infections are “mysterious” with no well known cause and little to no decent treatment, but we have tons of supposedly well researched body fat removal methods, about 20 different kinds of breast implants, laser hair removal, and 100 different dermatologist recommended anti aging creams. we sure had the money and brainpower to cure those “diseases”

[vs-griffin]

Pregnancy Rox: Positive Progress

I am over the moon excited. So last night, I was moved from my room in L&D to the extended stay antepartum wing. That means that I am not at risk for immediate delivery and that my outlook for reaching 34 weeks is higher in probability. All I can say is THANK GOD! This pregnancy has been a total journey into the unknown for sure. No, it’s not my first pregnancy however, it is my first pregnancy…

[coochiequeens]

This is why I can’t stand those stories about celebrities having kids through surrogates. They downplay the risks to the mother who goes through pregnancy and childbirth.

Fake or not, I mean I really hate to think of four kids dealing with an aunt/mom so oblivious to how those boys lost their mom so young and unwilling to modify plans but surrogacy does pose increased risks to the mothers and children they carry

“At the recent United Nations Commission on the Status of Women, The Heritage Foundation and the Center for Family and Human Rights drew attention to surrogacy and the dangers it poses to women at an event  that highlighted several instances of women who had been trafficked, rendered infertile, or even died as a result of surrogacy. Michelle Reaves was one such surrogate mother from California. She lost her life last year while delivering a baby for someone else, leaving her own son and daughter motherless and her husband a widower.

By its very nature, surrogacy commodifies both a woman’s body as well as that of the child. The women targeted to become a surrogate by the multi-billion-dollar fertility industry are often wooed by the opportunity to make tens of thousands of dollars in exchange for renting their body. In some cases, a surrogate arrangement is altruistic—perhaps the surrogate mother may want to help a friend or family member who desperately wants a baby, and she does not profit financially from the exchange. Nevertheless, regardless of the circumstances or motivation, in a surrogacy arrangement a woman’s body is used as a conduit for a transaction that provides a baby for someone else—and the risks for both her, and the baby, are significant.

Whether a surrogate mother is compensated or not, serious concerns involving health risks to mothers and babies remain, and the rights of children must not be ignored.

Children who are born as the result of a surrogacy arrangement are more likely to have low birth weights and are at an increased risk for stillbirth. When a woman carries a child conceived from an egg that is not her own—a traditional gestational surrogate arrangement—she is at a three-fold risk of developing hypertension and pre-eclampsia. Egg donors have spoken up about experiencing conditions such as loss of fertility, blood clots, kidney disease, premature menopause, and cancer, and the lack of data and studies on both short and long term health outcomes for egg donors makes true informed consent unattainable. While scientists do not fully understand the scope of these health considerations, it is clear that for both short and long-term outcomes, surrogacy is a frontier of unknowns; children, egg donors, and surrogate mothers may pay a physical or psychological price nobody yet fully knows or understands.”

[ottovonruthie]

Pregnancy complications can include conditions such as anemia, cholestasis of pregnancy, gestational diabetes, preeclampsia, ectopic pregnancy, placenta previa, placental abruption, preterm labor, hyperemesis gravidarum, miscarriage, stillbirth, infections, Rh incompatibility, gestational hypertension, and cervical insufficiency. And this isn’t even all of it. It’s beyond disrespectful to suggest a woman would go through all of that just to wait nine months to abort. No one endures the physical, emotional, and mental toll of pregnancy for nine months only to make that decision at the end.

[beyoursledgehammer]

Having gestational diabetes and hypertension issues in the hospital means all the stuff everyone wants to offer to make things easier is the opposite of what I need. I can't have snacks or candy because my blood sugar is monitored and I'm on insulin. Visitors are too stimulating and get my BP up too high and even if I'm enjoying them being here, I'm having anxiety simultaneously and then people get kicked out.

So instead I'm just sleeping a lot and eating sugar free jello and listening to the construction work going on outside my window.

[ginontherox]

Pregnancy Rox: Positive Progress

I am over the moon excited. So last night, I was moved from my room in L&D to the extended stay antepartum wing. That means that I am not at risk for immediate delivery and that my outlook for reaching 34 weeks is higher in probability. All I can say is THANK GOD! This pregnancy has been a total journey into the unknown for sure. No, it’s not my first pregnancy however, it is my first pregnancy…

[plant-bot]

Leech

Exhibit: Point Blue, Point Green

Beloved for their ability to cleanly store vast quantities of blood from different species, leeches have been a staple part of culinary and medicine for over 300 Mysteries. Leeches use a ring of microscopic teeth that ring the banded muscular mouth opening to pierce the flesh and also secrete a powerful compound that acts as anticoagulant, hypertensive and euphoriant all at once. Leeches do not understand the concept of "too much" and will gorge themselves on blood, much to their hosts detriment if not removed promptly.

They are found in areas that are sufficiently humid enough to accommodate their moist flesh. The limbs of the leech are covered in a highly vascularized pink tissue which constantly pumps and oxygenates the stored blood to keep it "fresh" as the creature relies on blood meals for digestion, gestation, and even as a hydraulic fluid that powers the limbs.

Leeches have been known to show individual preferences when it comes to blood - some will prefer to feed on sea dwelling animals, another may prefer cattloids, and some, may even be brave enough to feed off the blood from a rosebush.

[clonemedickix]

Again, sorry. Coping in the medical field is one of the hardest things to quantify, explain or manage. We often develop weird coping mechanisms and lone wolf tendencies. People struggle to understand our level of weird, while we struggle to maintain our sanity. I hope this is just a small glimpse into the mind of a good medic who can’t save everyone, but still cares deeply about continuing the fight.

Rating: M

Word count: 2.9K

Pairing: OC CMO Volte x OC General Lara Lin x OC Aurelia (by permission of @freesia-writes )

Warnings: Surgically assisted birth, coping with life risk, medical coping with reality of trauma and loss, discussing the feels

Excerpt Summary - Lara and Volte are required to deliver a child surgically; Volte has a flashback to times when he couldn’t save everyone and has a moment, struggling to cope.

@anxiouspineapple99 @blueink-bluesoul @523rdrebel @mandos-mind-trick @jediknightjana @moonlightwarriorqueen @wizardofrozz @lune-de-miel-au-paradis @dystopicjumpsuit @villanousace

Excerpt beneath the line

About six months into the girl’s pregnancy, Lara had noted her fiddling with her socks and boots, complaining how tight they were, and that her ankles were swelling up daily. Sliding over near her, Lara asked her how she’d been feeling, if she was excited about the coming baby. The girl, named Rhaela, chattered on in happiness about her preparations, how they’d made clothes and furniture for the baby, how excited Falco was about becoming a father. Lara listened to her with a smile, but with rising concern, which turned to fear when she heard Rhaela complain about the frequent headaches she was getting. Hearing her complaints, Lara realized they were symptoms of a concerning pregnancy related condition - at the very least it was gestational hypertension, but was most likely preeclampsia. She would need to talk to Volte and Aurelia as soon as possible about treatment plans for Rhaela; there wasn’t much to offer really - no antihypertensives, no hospital to stash her in until delivery. She would be much like the millions of human women that had gone before her, doing their best to survive high risk pregnancies.

In the end, Lara’s fears came true. Rhaela went into labor and struggled to deliver her child. As the birth progressed, she was unable to bring the child out, not matter what techniques she and Volte used. Lara found herself looking at Volte silently, full of dread and knowledge. In a small lull, while Rhaela rested, Falco holding her hand desperately, his face full of concern, Lara and Volte consulted in the corner of the small home, Aurelia listening without a word.

“She’s not going to be able to deliver that baby, Volte,” Lara said softly.

“So what do you propose we do, General?” Volte’s tone was laced with desperation and unhappiness. He knew instinctively where this was going, and his heart hurt at the knowledge, the risks they were faced with taking.

“If we do a section, we can probably save the baby. It’s full term, and should be fine. But I’m not sure if we can save them both. The meds we have will depress the baby’s breathing and heart rate as well - we absolutely can’t go cutting on her without giving her pain meds. So, we won’t have much time to get the baby out.” Lara’s fine brows were drawn together in thought and distraction. “What do you think, Volte?”

Volte looked disturbed that she was deferring the decision to him. He gawped a little in surprise and panic. “I…I don’t know, General! You’ve done this before - I haven’t.”

Lara looked at him a little flatly. “If you’re going to be the doctor for this community, these decisions will come up. Even the best docs on Earth still struggle with this at times.” She glanced over at Rhaela, who was napping fitfully. “We have to ask Rhaela what she wants. While she sleeps, we can get stuff ready.” She looked up at Aurelia a little sharply, focused now on a task that they could accomplish. “Rely, go get the med packs and the IV equipment. The surgical packs are labeled as such. Bring those as well as the airway pack. Can you get it all?”

“I can get Howzer to help me. I’ll be right back!” Aurelia turned and ran from the home quickly, on a mission to get the equipment back as soon as possible.

Lara stepped over to Rhaela and Falco; reaching out she took the young woman’s wrist in her hand and felt her pulse, then glanced at the fetal heart rate monitor to see how the baby was doing. The signs were okay for now - both mother and child were resting for a moment. Falco stared at Lara’s face, fear hiding in the depths of his brown eyes. He could sense the General wasn’t happy with how the delivery was going. Rhaela stirred, waking groggily and looking up at Lara and her husband. Taking a breath, Lara braced herself for the conversation that had to happen now.

“Rhaela, we are having some trouble bringing the baby along. I’m not sure you’re going to be able to deliver without help.” Falco’s eyes hardened.

“What kind of help?,” he asked guardedly.

“Surgical help. We’ve reached the point where we have to make a choice. I can surgically open the womb and get the baby out, or both mother and child will likely die in the attempt to have the baby naturally.” Lara’s expression was as flat as she could make it, looking into both parent’s eyes. They both looked taken aback, slapped by the cold hand of reality and dread. “Before you make your choice, you have to know - there is a large chance that Rhaela could die. This surgery is not without risks. The bleeding associated is usually bad, and I can’t make you any guarantees, other than if we do nothing, you will certainly die. And the child.” Lara’s eyes were full of regret, that she couldn’t do more for them.

Rhaela and Falco looked at each other, seeing that the writing on the walls was dark and unhappy. Tears came to both their eyes, along with a mixture of physical pain; the contractions were starting to return. Lara reached out and took Rhaela’s hand, saying nothing, but offering her presence as support. The girl took a deep breath, leaned over into Falco’s chest and cried softly. Falco held her like he was trying to force the strength from his own body into hers. Looking up at Lara, he whispered, “There’s no other way?”

Lara shook her head sadly.

Tears fell from Falco’s eyes, and he closed them, holding Rhaela tightly. After a moment, Rhaela looked at Lara and took a breath. “Do it, General. I know you’ll do your best. You and Volte can do anything, I know it.”

The words touched Lara’s soul, and she couldn’t stop a rim of tears from filling her eyes. Squeezing Rhaela’s hand, she gave her a bracing smile, nodded and stood. Aurelia and Howzer walked into the home carrying the supply bags at that moment. Aurelia was focused, moving to place them on the table and already opening the compartments, knowing exactly what she was after. Howzer glanced over at Falco briefly, his face full of uncomfortable sadness for the couple, but unsure what his place was, or how to be of use in this situation. Lara looked up at the captain and said quickly, “Howzer, please go find Turk, Dorian and Primer - ask them to come here. I’m going to need their help. Be quick, please.” Her tone was a professional command and brooked no argument. Howzer hurried from the home to do as ordered.

Lara and Volte worked quickly to get the room set up for the procedure, laying out the items and sterile packs they would need. She and Volte would do the surgery, while Aurelia kept Rhaela medicated and sedated, and Lara planned to have Turk and Dorian help with her airway and the baby when delivered. Primer she needed to support Falco. She wouldn’t ask him to leave his wife and child, but she wasn’t going to have him there alone if the worst occurred. The men soon turned up as requested, and Lara explained their roles to them. They nodded solemnly and immediately got themselves in the proper mindset for the challenge ahead.

Aurelia got an IV started on Rhaela and the fluids hooked up without issue. Lara drew up the appropriate doses of meds to sedate the young woman, and to keep her under for the surgery. “Rely, these are good for the first few rounds of the induction, but you’ll probably have to draw up a few more doses from the vials.” Aurelia nodded succinctly. She knew her job. She helped get Rhaela settled in her bed with some protective sheeting beneath her to catch blood and fluids, and then washed up quickly, returning to the girl’s bedside to don gloves. Lara got everyone masked up and to their places, then nodded to Aurelia to push the first doses of sedation and pain medication. Looking into Rhaela’s eyes, Lara did her best to assure the brave girl as her green eyes started to get glassy with sleep and medications.

Once she was deeply under with the versed and fentanyl on board, Lara had Rely push a new medication - rocuronium - to temporarily paralyze the mother’s muscles and have her relaxed enough to allow a medical airway to be placed. Lara picked up her laryngoscope quickly, positioned herself behind Rhaela’s head, opened her mouth with her right hand, and inserted the blade of the laryngoscope to push the girl’s tongue out of the way and expose her vocal cords to Lara’s sight. She inserted the endotracheal tube with practiced ease, and removed the stylet within, attaching an AMBU bag to the end of the tube with one hand and skills long learned. Watching for chest rise, she saw Rely quickly listen with a stethoscope for breath sounds or gastric gurgling, but the girl glanced up at Lara with a confirming nod. The tube was in place correctly. Lara moved to tape it securely to Rhaela’s mouth and cheek, then handed monitoring of the airway and respiration to Turk. She and Volte washed up and opened the sterile surgical trays and equipment, Lara donning a sterile gown and gloves and setting the field up with Volte’s help. When she was done, he did the same, getting dressed for the procedure and stepping up to Rhaela’s side. The two surgeons looked at each other, took a breath and nodded.

“Okay for a quick time out, team. We are going to do this c-section on Rhaela because we’re out of options to deliver naturally. Turk, you have the airway. Dorian, for now you are waiting to catch the baby. Aurelia, you are in charge of monitoring the vitals and administering the meds. Volte - you got any questions?” Volte shook his head. “Okay, I’ll make the first incision.” Lara reached over to the table and removed a scalpel, placing her left hand on Rhaela’s abdomen, pulling the skin back slightly, and at the base of her uterus at the pubic line, made a cut about six inches long. Volte quickly dabbed at the welling blood with gauze.

Lara worked swiftly to get through the layers of tissues, avoiding important structures carefully until she could see the outer surface of the uterus. Looking up quickly at Dorian, she said, “You ready D? Two minutes to having this baby out.”

“I’m ready General,” he said quickly, poised with a couple of clean blankets, ready to accept the child from Volte, who would hand it off to Dorian.

“Okay here we go.” Lara quickly cut into the uterus, working to avoid going too deeply; she didn’t want to accidentally nick the baby. She carefully stretched the incision, trying to avoid making it too big; there was benefit to leaving the incision slightly tight so as to squeeze the infant’s lungs of amniotic fluid and mimic the passage through the birth canal. She felt for the little head and got her fingers around and under it, directing it to the incision she’d made and gently pulling it out. She and Volte paused for a moment to clean the field of all the amniotic fluid and blood present, and then Lara reached back into Rhaela’s womb to grasp the child’s shoulder. Lifting it towards the opening, she worked first one and then the other free, feeling the body slide more quickly now from its former home of nine months. Lara lifted the infant’s body free of Rhaela and placed it on the sterile field, over the gap between her legs, working with Volte to clamp and cut the umbilical cord and clean the surgical field again of blood. Free of his mother’s womb and the placenta now, Volte quickly handed the newborn over to Dorian, who enfolded the boy in the warm, clean blankets and quickly stepped over to another table to work at waking the baby up, vigorously wiping at the vernix covering his skin, stimulating him until the baby let out a breathtaking, loud squawk. Internally, both Lara and Volte sighed with relief at the sound, but were working quickly to get Rhaela’s c-section finished and her sewed back up.

Lara reached once more into her womb to deliver the placenta. She placed it on the sterile field as she had the baby, and Volte quickly assessed it for completeness, nodding to Lara when he checked it. “Complete, General.”

“Good. Good, good, good,” Lara breathed. She worked to clean Rhaela’s uterus out as best she could, irrigating and scraping it clean of any remnants of birth so there would be minimal risk of infection after. When she was satisfied, she started working to sew up the incision site, which required multiple layers of sutures. Satisfied that the uterus was no longer bleeding, Lara started working on closing Rhaela’s abdomen back up, and they finished when Volte put in the final sutures and staples. They wiped her belly clean, watching it for any last oozing, and then took deep breaths out of relief. Aurelia looked up at them with a smile that spoke volumes of her own happiness at their apparent success, and pride in what their small team had accomplished. Falco had gone over to meet and hold his new son, Dorian handing the baby off to the new father with a happy smile for his teammate. Primer had watched the whole affair with a look of silent concern and solemnity, and he only broke into a smile when he saw Lara stand to her full height, stretching her shoulders and letting out the tense breath she’d been holding the entire time.

Lara glanced over at her first in command, their eyes meeting quietly. He gave her a little one sided smile of pride and congratulations, and Lara smiled back beneath her mask. Then she looked at Volte. The medic looked strangely… distracted, even a little shattered for some reason. Like he was looking at a scene of devastation and not success. Lara’s brows knit a little in confusion and she reached over to him, touching his arm softly. “Volte? You okay?” His eyes snapped up to hers suddenly, as if his mind had been far away.

“I’m fine, General. Good work. We did good work.” He tried to make his words sound strong and sure, but Lara could hear a faint note of confusion still there, like he was lost in a memory he couldn’t shake.

“Help me get all this taken down and scrub out. Go get some air.” Lara felt concern for him, but wasn’t sure what was wrong. He did as she’d directed, getting all of the instruments back to their tray, helping her break down the sterile field and clean up from their work. Volte stripped off his gloves, gown and mask and then left the home almost as if chased by ghosts. Even Primer watched him go with a look of concern. Primer met Lara’s eyes, full of questions for Volte’s behavior. Lara shrugged and shook her head - she wasn’t sure what was wrong, but she had two patients to attend to at the moment and couldn’t do anything about Volte.

She quickly checked the baby and the mother over, assuring both herself and Falco that they were doing well. Aurelia and Turk sat with Rhaela for a while longer, monitoring her vitals and maintaining her airway. By the time Lara was finished with her work in the little home, Rhaela was breathing on her own and seemed to be stable. Lara ordered Turk to remove the breathing tube, and remained to watch the girl, making sure she continued breathing independently a bit longer. Aurelia looked up to Lara and said, “Go after Volte. I’ll stay until she wakes up.”

Lara looked at Aurelia gratefully, reached over and squeezed her shoulder, and turned to leave. Primer stepped over to her quickly, following her out the door. “Do you need me to go with you to find him?”

Lara shook her head. “I’ve got it. I don’t think this talk will follow a path you know much about. But thanks. Watch over them for me and if Rely needs something, come get me pronto, okay?”

Primer stopped walking and called to Lara’s retreating form, “Will do, General.” He watched her for a minute longer, the pride he felt in her swelling for a moment, then he turned and walked back to Falco’s home in silence.

Lara found Volte sitting on her little hill, listening to the waves. His eyes were distant and his mind was far away, tears falling softly down his cheeks. She studied him in profile for a moment; he didn’t even acknowledge that he’d noticed her, he was so distracted. Lara pursed her lips a bit and moved to sit next to him without a word. He’d come back eventually, and she would be here when he was ready to talk. It was well over an hour though, before she felt him take a deep breath, hesitate, and then reach for words.

“Sorry, General, I just kind of… lost myself there for a minute.” To be honest, he still sounded rather lost, Lara thought quietly. She looked over at him from the side, her blue eyes studying him silently. Lara waited for Volte to make the next move.

Volte saw her watching him patiently, and sighed. “You ever have those moments, when you wonder if you did everything you could for someone you didn’t manage to save?”

Oh, so many, Lara thought to herself quietly. She looked off, over the waves before them, losing herself in the question and a swell of memories. “We all have those moments, Volte. The frustration of loss, of not being able to best Death - every medical person faces that at some point, if not multiple times. It’s a sign that you’re a good one, someone who cares.” She met his eyes firmly, trying to convey the depth of her meaning.

Volte nodded as if she’d verified something to be right, that he’d been thinking. He looked down at the grass and pulled a blade, rolling it between his thumb and forefinger, focusing on it as if it were the most fascinating thing he’d seen in a long time. After a long pause, he said a little haltingly, “I know we didn’t lose this time, but when we were sewing her up, I suddenly remembered the face of another person, from the war. She was a citizen on Falucia, and had taken a bad shrapnel wound to the gut. She was bleeding to death, right there in front of me, and her husband was there, begging me to save her. She was pregnant, probably close to her due date. And I just remembered his voice as he pleaded with me, to save her life. To save the child.” Volte stopped, his mind working to deal with the flooding memories. “I couldn’t save either of them. I had no idea, no training, on how to deliver a child.” It had never come up in either conversation or education. It wasn’t something the GAR thought a combat medic would ever need, nor should waste money and time on teaching. “I watched her life drain away, knowing her baby was dying too, and could do nothing, but hold her hand, while her husband grieved beside her. I felt so helpless, so useless.” He bowed his head, bringing his hands up to cover his face, breathing deeply to steady himself.

Lara listened patiently; Volte had to tell the story himself, let the grief roll through him so he could address it properly. She watched as he came to grips with the truths of his past self, and where he’d come to now. The truth was, there were no better teachers than time and experience. And he was right - why would the Kaminoans have trained him for obstetrics? They weren’t bred for community health work - the GAR medics existed to put their brothers back together and keep them fighting. But Lara knew after her long years of life, that the bitterness of helpless loss could still rise up to choke a good medic regardless of the reality of their situation. There were times when she’d watched good people die in her arms, because the technology didn’t exist yet for her to help them.

The two sat in silence for a while, letting the sounds of nature wash over them. “Sorry I let it get to me back there, General. Seems kind of silly now, since the whole operation went so well.” Volte looked over at Lara with a slightly sheepish grin.

“There’s nothing to be sorry for. Every medical person I’ve ever met is haunted, Volte. Our ghosts follow us around, reminding us of what might have been if we could only just take that extra step, find that miracle cure, have the right equipment. I’ll be honest - the ghosts only multiply when you start working with children.” She stole a glance at him, seeing if he was following. Volte wore a look of foreboding, hearing her say that. Lara shrugged a little. “Adults have lived their lives, made mistakes, learned, experienced, while kids have their whole future ahead of them. Losing a child is like seeing someone completely robbed of everything they might be, stealing someone from the future that might have cured cancer or solved the greatest problem known to life. Plus, there’s the parents who brought that child into the world out of their love for each other. Children are hard. But man they’re brave. Holy shit, Volte, they’re the bravest patients you will ever know.”

Lara looked hard into his eyes, and he saw for a moment that there were tears in hers. “They will fight and fight and fight, having no idea what life really is, whether it will be rewarding or continued pain for them, but they don’t give up. The struggle I’ve seen them shoulder - children carry the weight of the world and don’t even know it, but yet they do it gladly, with an excitement no adult will ever get back. Those kids on Earth that I take care of on ECMO - they push Death back every day, playing with the medical staff, doing their therapy with a giant hose in their necks, strapped to their head, or coming out of their chest, and yet - THEY STILL FIGHT!” Lara stopped, her face truly awed at the memory of some of her patients. “I’ve seen a lot of death and suffering in my time, but no warrior I’ve ever met can equal the spirit of a child fighting for their life. It’s a strength only they possess and can tap into.”

Lara shook her head, looking down at the grass. A dark look crossed her face momentarily. “But when they run out of that strength, when we lose them no matter how valiantly they fought, it’s the most soul crushing thing to experience. And once they cross that veil, Volte, when you know they’ve turned away and you can’t get them back - you would do anything, ANYTHING, if you could just reach out and grab their hand, keep them with you.” Her eyes misted over a bit, seeing a memory from another time. “I’ll never forget the sound of a mother when her little boy let go. She howled - howled - with grief, a torn sound from the bottom of her soul. She pleaded for him to come back, because she knew - he’d crossed that divide. He’d turned away, and there was no coming back.”

Lara stopped for a long moment, tears silently falling down her cheeks. “The sound of her pain and loss will never leave me. Just like that lady on Falucia will never leave you. You will face loss, Volte; it’s just the reality of being a medical officer. We cannot win every time. And for every success, it seems you pay in the blood of another. But you can’t give up - you’re invaluable to Nidhogg, to your brothers and their families. You can’t let the ghosts stop you from saving others. We take the pain and the risk, challenge Death at every turn, fight back against the darkness, so that others might live. Ut alii vivant. Fighting and sacrifice was what you and I were made for. We were given strength, determination and stamina so that we could face both loss and victory in equal measure and continue on. You are courageous enough to keep going, even in the face of failure - it’s that tenacity and flame I saw in you the first day, that made me choose you for Dragon Company. And why I know without a doubt, that you will be the best physician I’ve ever known.” Lara put her hand on his shoulder and smiled at him proudly. “I won’t always be here to help. But I KNOW this colony - these people - are in the best hands.”

Her smile for him was firm and determined, sure in her words. She believed in Volte completely, and he could feel it. Volte looked down at the ground for a moment, absorbing all she’d told him. It was a daunting thing, looking to the future and knowing he would have to step up and make all the decisions himself sooner than later. Lara was right - she wouldn’t always be here to hold his hand. But knowing that she was behind him in thought and spirit, knowing she believed in him utterly - that meant so much to him. He could do his job, knowing he had her support and faith. Volte met his General’s eyes steadily and nodded, a small shy smirk forming on his face. “Thanks, General. For everything.” She gave him a small smirk back and nodded, then turned away to watch the gulls flying over the water before them. The two sat in companionable silence for a long time, two best friends bonded by mutual experience, mission and their ghosts.

[wishingforatypewriter]

Pregnant Lin head cannons ? Was conceiving easy for her or was she infertile ? What symptoms does she experience ? What cravings does she have ? Any complications ? How does the birth go ? After birth what is her postpartum experience like ? Does she experience ppd ? Is breastfeeding easy for her ?

Hi! Thanks for the ask! (I'd like to preface this post with a disclaimer that I have never been pregnant, so this may not be entirely accurate)

Lin conceived relatively easily and never had any fertility issues. Her pregnancy was actually unplanned.

She had pretty bad morning sickness during her first trimester. She was especially sensitive to smells and sometimes the scent of certain ingredients cooking would make her queasy. She also experienced a lot of fatigue during her pregnancy and needed a lot more sleep than she was used to.

Lin's biggest craving was for citrus fruits like tangerines and pomelos Her partner would always make sure the apartment was well stocked with them, and peel them for her when she wanted a snack. (I wrote a linzolt oneshot called Tangerines around this idea). Her pre-existing love of spicy foods was intensified while she was pregnant, so she ate a lot of fire noodles and fire flakes.

Because she was having twins, Lin was at a higher risk for preterm labor and gestational hypertension. However, her medical team (including Katara) monitored the situation and she ultimately didn't experience those effects.

Lin has a pretty high threshold for pain, but nothing could have prepared her for childbirth. She was in labor for fourteen hours and it was a bit of an ordeal. Her partner was with her the whole time, holding her hand and feeding her ice chips and sips of water.

When she came home from the hospital, Lin's partner did not let her lift a finger. She got to rest and recover from the birth, taking naps and listening to probending on the radio and just bonding with her new babies. Her partner took care of everything around the house so she could relax.

Lin doesn't have postpartum depression, but she does experience some anxiety around being a new mom.

Breastfeeding is relatively easy for her, but after a few weeks she switches to bottle feeding because she wants to start checking in with Saikhan at the RCPD.

[jcsmicasereports]

Paroxysmal Sympathetic Hyperactivity As A Cause Of Prolonged Icu Stay- Case Report by Arnab Choudhury in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

Paroxysmal Sympathetic Hyperactivity (PSH) is commonly described in patients after Traumatic Brain Injury but it can present after an ischemic stroke following a complicated surgery. Usual clinical presentation are tachycardia, tachypnea, hypertension, sweating with seizures and dystonic posturing less likely initial signs. High grade fever and profuse sweating may allude sepsis or epilepsy leading to extraneous administration of anti-epileptics and antibiotics. Suspicion of pheochromocytoma arises in such situations which is ruled out by CECT. Clonidine (α-2 blocker), propranolol (β-blocker) and Baclofen (GABAb agonist) are agents used in treatment. Benzodiazapenes like lorazepam are important part of treatment as discontinuing them can exacerbate PSH attacks. MRI brain with MR angiography usually reveals hyper-intensities on T2/FLAIR in subcortical areas (thalami, cerebellum, crus cerebri) and restricted diffusion with low ADC values. Recurrent PSH episodes can occur due to delay in diagnosing and treatment leading to contractures and difficulty weaning the patient off the ventilator with tracheostomy tube placed. This case presents a scenario in which the delay in diagnosing PSH led to extensive investigations , delay in specific treatment and a prolonged ICU stay of the patient. Mainstay of rehabilitation remains aggressive physiotherapy to improve contractures if any, medications for the autonomic fluctuations and regular follow up.

Keywords : Sympathetic, hyperactivity, paroxysmal, brain, episodes

Introduction

Paroxysmal sympathetic hyperactivity (PSH) is a disorder of autonomic function regulation most commonly observed in patients with acute brain injury. It mostly occurs after traumatic brain injury, but it can also occur after non-traumatic brain diseases such as anoxic-ischemic coma after cardiac arrest, intracranial haemorrhage, and ischemic stroke-[1].

The core clinical features include - tachycardia, tachypnea, hypertension, sweating , hyperthermia and  posturing-[2]. These episodes are mostly triggered by some external stimuli such as pain , movement , and urinary retention . PSH occurs due to diffuse or focal brain injuries that disconnect one or more cerebral centers from the caudal excitatory centers and the disconnection of descending inhibitory pathways causing spinal circuit excitation.

Tonic posturing during  episodes can mimic tonic seizures, and the raised temperature can mimic infection, which can lead to unnecessary investigations, delays in proper management and prolonged ICU stays. Here, we are presenting one such case.

Case Presentation

A 32-year-old woman (gravida 2 and para1) had pain in the lower abdomen at week 31 of gestation for which she was hospitalized and emergency Lower Segment Cesarean Section was performed in view of fetal hypoxia. On the 2nd day post-delivery, she developed multiple episodes of seizures without regaining consciousness in between and was intubated for airway protection.  Brain Magnetic Resonance Imaging(MRI) with angiography suggested posterior circulation ischaemic stroke with bilateral narrow caliber of both vertebral arteries and a left fetal PCA. She was started on antiepileptic drugs and secondary prophylaxis for stroke. She was having high-grade fever and, multiple episodes of profuse sweating per day. Blood counts, cultures, and other markers of infection gave negative Results. She had episodes of tachycardia, tachypnea, hypertension, and sweating associated with fever.

The fever episodes created difficulty in weaning the patient from the ventilator.Therefore, she was started on clonidine and later on, propranolol;-however, these episodes continued to occur. Suspecting pheochromocytoma, abdominal contrast enhanced computed tomography (CECT) was performed, but the results were normal. The patient had recurrent episodes of increase in whole body tone (Fig 1) associated with bilateral lower limb tremors, abnormal posturing along with the above-mentioned episodes of fever. Initially, it was assumed that the rigors were those associated with fever, but later,speculating that the rigors were seizures,- the dosage of herantiepileptic medications were increased, and she was administered triple antiepileptics ( valproic acid , levetiracetam and lorazepam). Her brain EEG showed no epileptiform discharges. Despite receiving triple antiepileptics, she continued to show seizure-like activity. Later, these episodes of fever, tachycardia, tachypnea, hypertension , sweating and increase in body tone occurred simultaneously,- and the diagnosis of paroxysmal sympathetic hyperactivity was made.

The patient was administered clonidine, propranolol, and baclofen. Her episodes of sympathetic hyperactivity were controlled .  Later, her empirical antibiotics were stopped as there was no evidence of infection and fever was explained as a part of sympathetic hyperactivity. Antiepileptic medications were tapered off to only levetiracetam. However, after discontinuing valproate and lorazepam she again started experiencing episodes of sympathetic hyperactivity. Therefore, lorazepam was reintroduced to control her symptoms. Finally, the patient was weaned off ventilator support and shifted to the ward.

Investigations

Blood parameters: TLC - 10,000 /mm3 ,Hb - 12 g/dl , Platelets - 2.8 lac/mm3

Blood culture - no pathogenic organism grown after 48 hrs of aerobic incubation.

Urine culture - sterile

Endotracheal aspirate culture - no pathogenic organism grown after 48 hrs of aerobic incubation.

High vaginal swab culture - normal vaginal flora grown.

Procalcitonin - 0.29 ng/ml

CSF analysis, - Acellular; sugar,-24 mg/dl; protein,-68 mg/dl; culture,-sterile

Dengue IGM,- negative; ICT and peripheral smear for Malaria - negative , Typhidot IGM,- negative; scrub typhus IGM,- negative.

Ultrasound abdomen:- no significant abnormality.

MRI Brain with MR Angiography –The brain stem appeared bulky and showed T2/FLAIR hyperintense signal. Similar areas with T2/ FLAIR hyperintense signal were also seen involving the thalami, right crus cerebri and bilateral inferior cerebellar peduncles. Many of these areas showed restricted diffusion with low Apparent Diffusion Coefficient (ADC) values. The bilateral (right > left) vertebral and distal basilar arteries appeared significantly attenuated in caliber. The right PCA appeared to be significantly attenuated in caliberas compared with fetal origin of the left PCA.

EEG - Generalized cerebral dysfunction; -no epileptiform-discharges.

CECT abdomen - No significant abnormality

Outcome and Follow-up

The episodes of sympathetic hyperactivity resolved, and the patient was shifted to the  ward from the ICU with tracheostomy in room air. She developed contractures owing to persistent decerebrate posturing. Aggressive physiotherapy was administered. In the ward she regained her sensorium and was discharged with a GCS score of E4VTM6 for further follow-up in the OPD.

Discussion

A significant minority of patients who survive acquired brain injury develop sympathetic hyperactivity, which includes episodes of periodic increase in heart rate and blood pressure, sweating, hyperthermia, and motor posturing, often in response to external stimuli, which can last for weeks or more months-[3].Some studies argue that it is common but often unrecognized-[4].Most studies have reported paroxysmal sympathetic hyperactivity after traumatic brain injury. Fewer cases have reported it to be a sequel of brain stroke following prolonged hospital stay.Though commonly seen in TBI, PSH has rarelybeen described in patients with brainstem strokes and anoxic brain injury-[5].PSH may be mistaken for sepsis, which may lead to unnecessary treatment with antibiotics and prolonged hospital stays-[6].Fever is relatively common among patients in the intensive care settings. Although the most obvious and concerning etiology is sepsis, PSH may be the underlying etiology-[7].There are diencephalic structures analogous to the cerebral motor cortex that are capable of producing, when irritated, paroxysmal motor discharges  similar to the focal discharges described as epilepsy-[8].PSA may be camouflaged by epileptic seizures, leading to the unwarranted administration of antiepileptics to the patient. Obstetric patients can present with acute increases in heart rate,-BP and the onset of HELLP syndrome mimicking PSH. Epigastralgia, hypertension, and tachycardia necessitate cesarean section, as in our case, with the subsequent development of HELLP syndrome mimicking PSH.An acute fluid shift from the splanchnic vasculature to the central vasculature may have occurred, causing HELLP syndrome as a result of vasospasm associated with sympathetic hyperactivity. Reporting such cases will facilitate in understanding if the reverse is true, that is, if PSH can mimick as HELLP syndrome-[9,10]. Pregnancy is a risk factor for paroxysmal sympathetic hyperactivity exacerbation, and delivery can result in resolution of the condition-[11].PSH is reclassified as a sympathetic storm rather than an epileptic disorder because of its unresponsiveness to anti-epileptics and the absence of epileptic activity on EEG. [12]it is crucial for clinicians to distinguish this disorder from paroxysmal dystonias. [13,14]Sympathetic storms have been linked to dystonia-like posturing (e.g., PAID, i.e., "paroxysmal autonomic instability with dystonia")[15], Antidopaminergic medications are best avoided to minimize the risk of neuroleptic malignant syndrome, which can potentially mimic PSH (dysautonomia). In contrast to delirium‐associated persistent agitation and picking‐like behaviours, PSH movements are episodic, tend to be provoked by touch, and are uniquely associated with increased sympathetic activityIn the management of this disorder opiates, γ-aminobutyric acid agents, dopaminergic agents, and β-blocker pharmacological agents have been studied. There is a lack of recommendations and comparisons of agents for the management of this disorder.  There is a paucity of recommendations and comparisons of agents for the management of this disorder.  Monotherapy is usually ineffective for the management of paroxysmal sympathetic hyperactivity, and multiple agents with different mechanisms of action should be considered, as in our case .β-blockers have proven to be therapeutic (not as monotherapy) as in our case,α-agonists such as dexmedetomidine have reported therapeautic efficacy in many studies. However, clonidine another α-agonist has shown therapeutic efficacy, as in our case. The effectiveness of physiotherapy in PSH is rarely reported in medical journals; our case strives to provide an example of such therapeutic benefits.

Conclusion

Paroxysmal sympathetic hyperactivity is quite common in patients with brain insult.It can mimic seizures and/or sepsis (due to high grade fever) leading to unnecessary investigations, exposure to higher-grade antibiotics and antiepileptics. Benzodiazepines are beneficial in controlling sympathetic hyperactivity.Non recognition of PSH can lead to difficulty in weaning patients off the ventilator and prolonged hospital stays. Recurrent episodes of sympathetic hyperactivity can lead to significant weight loss and contractures.

[visionarystoryteller]

2months ago, I gave birth to my baby boy, two months!

I had to have him 4 weeks early due to gestational hypertension, but he was so healthy. Me on the other hand probably shouldn’t be bc my bp was over 200 at one point but they fixed it. Can y’all believe this kid legit slid out of me, like legit was already head out by the time my water broke. Thank god I had no tearing, I was extremely lucky on that part. On all parts really, I barely felt much even when they were doing my epidural.

Now I sit here with my two month old who is one of the cutest little boys, I’m biased but whatever, always such a good baby and lovessssss his cuddles.

[coochiequeens]

Ladies, being a surrogate carries a higher risk for complications. Don't let anyone try to guilt or pay you into being one if you don't want to.

By Will Pass September 26, 2024

Gestational carriers face a significantly higher risk for severe maternal morbidity and other pregnancy complications than those conceiving naturally or via in vitro fertilization (IVF), according to a recent Canadian study.

These findings suggest that more work is needed to ensure careful selection of gestational carriers, reported lead author Maria P. Velez, MD, PhD, of McGill University, Montreal, Quebec, Canada, and colleagues.

"Although a gestational carrier should ideally be a healthy person, with a demonstrated low-risk obstetric history, it is not clear whether this occurs in practice," the investigators wrote in Annals of Internal Medicine. "Moreover, the risk for maternal and neonatal adversity is largely unknown in this group."

Study Compared Gestational Carriage With IVF and Unassisted Conception

To address these knowledge gaps, Velez and colleagues conducted a population-based cohort study in Ontario using linked administrative datasets. All singleton births at more than 20 weeks' gestation with mothers aged 18-50 years were included from April 2012 to March 2021. Multifetal pregnancies were excluded, as were women with a history of infertility diagnosis without fertility treatment, and those who underwent intrauterine insemination or ovulation induction.

Outcomes were compared across three groups: Unassisted conception, IVF, and gestational carriage. The primary maternal outcome was severe maternal morbidity, defined by a validated composite of 41 unique indicators. The primary infant outcome was severe neonatal morbidity, comprising 19 unique indicators.

Secondary outcomes were hypertensive disorders, elective cesarean delivery, emergent cesarean delivery, preterm birth at less than 37 weeks, preterm birth at more than 32 weeks, and postpartum hemorrhage.

Logistic regression analysis adjusted for a range of covariates, including age, obesity, tobacco/drug dependence, chronic hypertension, and others. The final dataset included 846,124 births by unassisted conception (97.6%), 16,087 by IVF (1.8%), and 806 by gestational carriage (0.1%).

The weighted relative risk (wRR) for severe maternal morbidity was more than three times higher in gestational carriers than in those conceiving naturally (wRR, 3.30; 95% CI, 2.59-4.20) and 86% higher than in those conceiving via IVF (wRR, 1.86; 95% CI, 1.36-2.55). These stem from absolute risks of 2.3%, 4.3%, and 7.8% for unassisted, IVF, and surrogate pregnancies, respectively.

Moreover, surrogates were 75% more likely to have hypertensive disorders, 79% more likely to have preterm birth at less than 37 weeks, and almost three times as likely to have postpartum hemorrhage.

These same three secondary outcomes were also significantly more common when comparing surrogate with IVF pregnancies, albeit to a lesser degree. In contrast, surrogate pregnancies were associated with a 21% lower risk for elective cesarean delivery than IVF pregnancies (wRR, 0.79; 95% CI, 0.68-0.93).

Severe neonatal morbidity was not significantly different between the groups. These findings add to a mixed body of evidence surrounding both maternal and neonatal outcomes with gestational carriers, according to the investigators.

"Prior small studies [by Söderström-Anttila et al. and Swanson et al.] reported varying risks for preterm birth in singleton gestational carriage pregnancies, whereas a recent large US registry reported no increased risk for preterm birth compared with IVF, after accounting for multifetal pregnancy," they wrote. "This study excluded multifetal pregnancies, a common occurrence after IVF, with reported higher risks for adverse outcomes. Accordingly, adverse maternal and newborn outcomes may have been underestimated herein."

Causes of Worse Outcomes Remain Unclear

While the present findings suggest greater maternal morbidity among surrogates, potential causes of these adverse outcomes remain unclear.

The investigators suggested that implantation of a nonautologous embryo could be playing a role, as oocyte donation has been linked with an increased risk for hypertensive disorders of pregnancy.

"We don't know exactly why that can happen," Velez said in an interview. "Maybe that embryo can be associated with an immunological response that could be associated with higher morbidity during pregnancy. We need, however, other studies that can continue testing that hypothesis."

In the meantime, more care is needed in surrogate selection, according to Velez.

"In our study, we found that there were patients, for example, who had more than three prior C-sections, which is one of the contraindications for gestational carriers, and patients who had more than five [prior] pregnancies, which is also another limitation in the guidelines for choosing these patients," she said. "Definitely we need to be more vigilant when we accept these gestational carriers."

But improving surrogate selection may be easier said than done.

The quantitative thresholds cited by Velez come from the American Society for Reproductive Medicine guidelines. Alternative guidance documents from the Canadian Fertility and Andrology Society and American College of Obstetricians and Gynecologists are less prescriptive; instead, they offer qualitative recommendations concerning obstetric history and risk assessment.

And then there is the regulatory specter looming over the entire field, evidenced by the many times that these publications cite ethical and legal considerations — far more than the average medical guidance document — when making clinical decisions related to surrogacy.

Present Study Offers Much-Needed Data in Understudied Field

According to Kate Swanson, MD, a perinatologist, clinical geneticist, and associate professor at the University of California San Francisco, the present study may help steer medical societies and healthcare providers away from these potential sand traps and toward conversations grounded in scientific data.

"I think one of the reasons that the Society for Maternal-Fetal Medicine and the maternal-fetal medicine community in general hasn't been interested in this subject is that they see it as a social/ethical/legal issue rather than a medical one," Swanson said in an interview. "One of the real benefits of this article is that it shows that this is a medical issue that the obstetric community needs to pay attention to."

These new data could help guide decisions about risk and candidacy with both potential gestational carriers and intended parents, she said.

Still, it's hard — if not impossible — to disentangle the medical and legal aspects of surrogacy, as shown when analyzing the present study.

In Canada, where it was conducted, intended parents are forbidden from paying surrogates for their services beyond out-of-pocket costs directly related to pregnancy. Meanwhile, surrogacy laws vary widely across the United States; some states (eg, Louisiana) allow only altruistic surrogacy like Canada, while other states (eg, California) permit commercial surrogacy with no legal limits on compensation.

Swanson and Velez offered starkly different views on this topic.

"I think there should be more regulations in terms of compensating [gestational carriers]," Velez said. "I don't think being a gestational carrier should be like a job or a way of making a living."

Swanson, who has published multiple studies on gestational carriage and experienced the process as an intended parent, said compensation beyond expenses is essential.

"I do think it's incredibly reasonable to pay someone — a woman is taking on quite a lot of inconvenience and risk — in order to perform this service for another family," she said. "I think it's incredibly appropriate to compensate her for all of that."

Reasons for compensation go beyond the ethical, Swanson added, and may explain some of the findings from the present study.

"A lot of these gestational carriers [in the present dataset] wouldn't necessarily meet criteria through the American Society of Reproductive Medicine," Swanson said, pointing out surrogates who had never had a pregnancy before or reported the use of tobacco or other drugs. "Really, it shows me that a lot of the people participating as gestational carriers were maybe not ideal candidates. I think one of the reasons that we might see that in this Canadian population is…that you can't compensate someone, so I think their pool of people willing to be gestational carriers is a lot smaller, and they may be a little bit less selective sometimes."

Velez acknowledged that the present study was limited by a shortage of potentially relevant information concerning the surrogacy selection process, including underlying reasons for becoming a gestational carrier. More work is needed to understand the health and outcomes of these women, she said, including topics ranging from immunologic mechanisms to mental health.

She also called for more discussions surrounding maternal safety, with participation from all stakeholders, including governments, surrogates, intended parents, and physicians too.

This study was funded by the Canadian Institutes of Health Research. The investigators disclosed no conflicts of interest. Swanson disclosed a relationship with Mitera.

Will Pass, DVM, is a veterinarian and freelance medical writer from Colorado.