Thoracic Spine Product
These methods (epidural anesthesia, spinal anesthesia, or a combination of both methods) are commonly used for pain relief during labor or for cesarean deliveries because they are immediately effective, the failure and complication rates are low, ambulation is possible, and they do not seem to interfere with the progress of labor (Mattingly 2003, Albright 2000). Among the many anesthetics used are iido-caine, bupivacaine, ropivacaine, and fentanyl. These agents have already been discusscd individually (see above). Most studies looking at the effects of this type of anesthesia on the newborn infant showed some slight and transitory effects, with clearing of symptoms and elimination of the drugs from the infant's circulation within 24 hours. There seem to be no studies on the possible long-term effects of epidural spinal analgesia on the development of the children.
The spine is one area that even most novices at ultrasound can easily find. Take a look at it in Figure 21-3. In the second trimester, imaging the entire spine is important in order to rule out neural tube defects (see Chapter 8). You can easily see the fetal spine on ultrasound in the second trimester. You can easily see the fetal spine on ultrasound in the second trimester.
Neural tube defects (NTDs), a group of heterogeneous malformations involving neural tissue in the brain and or spinal cord, occur in less than 1 per 1,000 births in the United States 16 . The etiology of NTDs is an ongoing area of research however, inadequate maternal folate status prior to and in the first few weeks after conception appears to play a role in at least some cases of neural tube defects. According to 1999-2000 National Health and Nutrition Examination Survey (NHANES) data, the average folate intake of 20- to 39-year-old women in the United States is 327 mcg day 17 . Results from supplementation studies suggest that women capable of becoming pregnant should consume an additional 400 mcg day of folic acid from supplements and or fortified foods in addition to consuming food folate from a varied diet.**
It is important to take a diet balanced in calories, carbohydrates, proteins and fibers. Folic acid is a type of vitamin B that is needed for the formation of blood cells and the development of baby's nervous system. It has been shown to reduce the chance of a baby having neural tube defects (spinal cord and brain abnormalities) (Figure 1.2). A simple Figure 1.2 Defect at lower spine (arrow). Figure 1.2 Defect at lower spine (arrow).
Epidurals are the most commonly used form of pain relief in some hospitals, 80 to 90 percent of women get them. This method of anesthesia numbs the woman below the waist but leaves her fully conscious. Unlike narcotics, which are simple to give, epidurals require a thin plastic catheter to be inserted through a needle into the woman's lower back and then into the epidural space just outside the membrane covering the spinal cord. Drugs usually local anesthetics flow through the catheter and temporarily numb the nerves that provide feeling below the waist. Because this procedure requires a trained anesthesiologist, not all hospitals offer it. Spinal block. Similar in effect to an epidural, this is often used for cesareans.
Lateral radiograph of the spine showing the bone-in-bone appearance of the vertebral bodies. This is a striking example of growth arrest but otherwise is a nonspecific finding. Hemivertebrae may occur in the cervical or thoracic spine, and less commonly in the lumbar spine. An isolated hemivertebra may not be recognized clinically but can cause abnormal posture (scoliosis). More commonly, hemivertebrae are multiple and may be associated with other skeletal abnormalities, as in the ribs. Figure 1.7. Congenital scoliosis is rare in neonates but may occur in association with structural anomalies of the vertebral spine. In this infant, the congenital scoliosis was associated with abnormal segmentation of vertebrae. Figure 1.9. Lateral view of the same infant showing the prominent end of the spine and arthrogryposis of the lower extremities.
Some birth defects, genetic diseases, and chromosomal problems can be diagnosed prenatally, especially if the mother has had an ultrasound or amniocentesis performed. (See Chapter 1, Prenatal Care, for more information about these tests.) These conditions include spina bifida (in which the spinal cord doesn't close properly), Down syndrome, some heart malformations, and cleft lip or palate. Many of these conditions are described in Chapter 32, Health Problems in Early Childhood.
Under the influence of estrogen, progesterone, and elastin, pregnancy is associated with generalized connective tissue laxity, potentially leading to ligament and joint instability 1 . Additional strain on the musculoskeletal system comes from the change in the body's center of gravity, resulting in progressive lordosis (accentuation of the lumbar curvature of the spine) and kyphosis (curvature of the upper spine) 7 . The change in center of gravity requires greater muscular effort with certain movements, such as rising from a squatting or sitting position or changing directions quickly. The progressive lordosis in pregnancy frequently results in lower back pain, which could be prevented by improving posture and muscular strength preferably prior to pregnancy 8 such preventative measures are also effective during pregnancy 9 . Providing exercise guidelines to increase core strength prior to pregnancy minimizes these injuries.
The safety and efficacy of the different strategies for labor analgesia have been discussed extensively in the literature during the last decade. There arc reports claiming that systemically administered pethidine (and other opioids) lack analgesic effectiveness for labor pain, but serve primarily to sedate the mother and, inadvertently, the neonate (Reynolds 1997, Olofsson 1996). Other strategies discussed include paracervical block, spinal blockade and epidural analgesia with local anesthetics or opioids. Combinations of epidural with parenteral analgesia and of epidural with spinal analgesia are also used (Eberle 1996). Epidural analgesia seems to be very effective in reducing pain during labor, but may also have some adverse effects.
Backaches are a common symptom that many women experience during pregnancy. They typically occur in the latter part of pregnancy, although they can occur earlier. The shift in your center of gravity can be one cause. Another can be the change in the curvature of your spine as the baby grows and the uterus enlarges. You may get some relief by getting off of your feet when you can, applying mild local heat, and taking acetaminophen (Tylenol). Our patients often ask us about using a specially designed pregnancy girdle that they've seen advertised or heard about. Although some patients say this girdle helps, others don't think so.
The drug rapidly crosses the placenta into the fetal circulation and amniotic fluid (3,4,5. and 6). Studies in patients undergoing elective abortions in the 1st and 2nd trimesters indicate that amikacin distributes to most fetal tissues except the brain and cerebrospinal fluid (3,5). The highest fetal concentrations were found in the kidneys and urine. At term, cord serum levels were one-half to one-third of maternal serum levels whereas measurable amniotic fluid levels did not appear until almost 5 hours after injection (4).
Pilates is a popular mind-body conditioning program focused on strengthening the core postural muscles important in maintaining your balance and supporting your spine. For the most part, continuing Pilates classes while you are pregnant is safe, as long as you avoid lying flat on your back for long periods of time.
Martinez-Frias et al.69 analyzed 19,577 consecutive infants with malformations of unknown cause and compared those born to mothers with GDM with those of nondiabetic mothers. Their findings indicated that GDM is a significant risk factor for holoprosencephaly, upper lower spine rib anomalies, and renal and urinary system anomalies. However, owing to the heterogeneous nature of GDM, which includes previously unrecognized and newly diagnosed Type 2 DM, they could not rule out the possibility that the teratogenic effect is related to latent Type 2 DM. Nevertheless, they concluded that pregnancies complicated by GDM should be considered at risk for congenital anomalies.
It is usually given in conjunction with an ultrasound scan (MacLachlan 1992). A high level of AFP in the blood might indicate that the pregnancy is more advanced than realised, a multiple pregnancy, a spinal tube defect such as spina bifida, Turner's syndrome (very rare) or death of the baby.
Based on the observation of more than 15 000 pregnancies, there was no increased risk of spontaneous abortion and no increase in birth defects or prematurity (Harjulehto-Mervaala 1995, Ornoy 2006, 1993, 1990). The authors consider the oral poliovirus vaccine as safe for pregnant women however, it should not be used in the last month of pregnancy, to avoid contamination of delivery rooms by the virus-shedding mother. Live attenuated poliovirus is no longer relevant as a result of practical extinction of the disease, at least in the developed world. Polio-like changes (damage to the anterior horn cells of the spinal cord) were noted in a fetus aborted at 21 weeks' gestation when the previously immune mother received oral polio vaccine at 18 weeks (Castleman 1964), but no similar effect has been published since.
The embryo continues to develop rapidly, tripling in siz e i n seven days. It is sh aped like a ki dn ey bean . On either side of the spinal column, there are n ow vertebrae developin g, and from between these, nerve cells radi ate in an incre asin gly complex nervous system that reaches every part of th e body. This network of nerves has two very important functions it transmits to all muscles, tellin g th em when to contract and it passes in formation to the brain about the stimuli the nerves c an regi ster sen sati ons such as h e at , p ai n , or pressure.
Blood urine toxicology would be beneficial to rule out substance misuse. Cerebrospinal fluid (CSF) examination is beneficial if an infection is suspected6, and for the presence of blood if a SAH is suspected7. If cardiac origin is suspected, an ECG and echocardiogram should be performed.
Multiple Sclerosis (MS) is an unpredictable, progressive demyelinating disease that affects the central nervous system (CNS) at different levels and at varying times4. It is a chronic, disabling condition5. The white matter within the brain or spinal cord becomes inflamed then destroyed by the person's own immune system. The inflamed areas of myelin sheaths on neurons deteriorate and become scarred to become scleroses in multiple regions. This destruction of the myelin sheath slows and short-circuits the conduction of nerve impulses5, resulting in neurological symptoms. Often there is an acute onset of symptoms, including
This is a rare condition in which women present with severe back pain and height loss due to vertebral collapse, usually in the third trimester of pregnancy. Often the diagnosis is not made until after delivery. Lateral spinal X-rays will show vertebral collapse. The aetiology is not clear but may be related to previous prolonged amenorrhoea, anorexia nervosa or mild forms of osteogenesis imperfecta. Osteogenesis imperfecta is an inherited bone disorder due to defective collagen known colloquially as 'brittle bone disease' that results in fractures of varying frequency and severity.
Local anesthetics, if absorbed, may stimulate the central nervous system and inhibit electrical stimulation of the heart. Noradrenaline (norepinephrine) or adrenaline (epinephrine) are often added to produce vasoconstriction, limiting local anesthetic uptake by the circulatory system. Local anesthetics are either esters, which are quickly deactivated in tissue by non-specific esterases, or amides, which are more slowly deactivated by amidases. Generally, these local anesthetics are wcll-tolcratcd in all phases of pregnancy, and they seem to have no effect on the neurophysiologic state of the newborn. Local anesthetics, whether injected into various organs, the epidural space or the cerebrospinal fluid, can also reach the fetus. Following epidural anesthesia, cord blood levels were about half the maternal blood levels (Guay 1992, Sakuma 1985). In pudendal nerve block, the levels in cord blood are much lower (Sakuma 1985). No specific teratogenic effects have been described in human...
Acute attacks of asthma during labor and delivery are extremely rare, and women should be reassured accordingly. Regularly scheduled medications (both inhalers and even steroids) should be continued during labor. For induction of labor, the use of Prostin (Prostaglandin E2), which is a bronchodilator, is safe. Women with asthma may safely use all forms of pain relief in labor, including epidural analgesia and Entonox (see Chapter 37). If cesarean section is required, women should be encouraged to have a regional (spinal or epidural) rather than general anesthesia because of the increased risk of severe bronchospasm and chest infection.
NTDs are congenital defects that occur if the developing neural tube fails to close properly during the third or fourth week of embryonic development. Anencephaly is one form of NTD where the cranium fails to form or close, and this results in either miscarriage, stillbirth, or neonatal demise. In the first trimester, before any interventions take place, the incidence of anencephaly and spinal NTDs (spina bifida) is approximately equal. There are conflicting reports concerning a direct but weak association between maternal age and the incidence of NTD (4), and most screening programs do not take maternal age into consideration. Hydrocephalus is present in approximately one-third of OSB cases because of disrupted cerebrospinal fluid (CSF) circulation. ONTDs include both OSB and anencephaly, and both are detectable with second-trimester maternal serum biochemical screening and carefully targeted ultrasound. Closed spina bifida is not usually detected prenatally and is relatively less...
When you're in the recovery room, your nurse and anesthesiologist monitor your vital signs. The nurse periodically checks your abdomen to make sure that the uterus is firm and that the dressing over the incision is dry. Your nurse also checks for signs of excessive bleeding from the uterus. More than likely, you have a catheter in your bladder, and it stays in place for the first night so that you don't have to worry about getting up to go to the bathroom. You also have an intravenous (IV) line in place to receive fluids and any medications your doctor prescribes. If you had an epidural or spinal anesthetic, your legs may still seem a little numb or heavy. This feeling wears off in a few hours. If you had general anesthesia (that is, if you were put to sleep ), you may feel a little groggy when you get to the recovery room. Just as with a vaginal delivery, you may experience some shaking (see Chapter 10). If you're up to it and if you want to, you can breastfeed your baby while you're...
This type of anesthesia involves administering medications through a thin catheter that has been inserted into the space surrounding the spinal cord in the low back, causing loss of sensation of the lower body. The amount of medication may be increased or decreased as needed. This type of anesthesia is used during labor and for vaginal and cesarean deliveries. The most common complication of epidural anesthesia is low blood pressure in the mother, and most woman need to receive intravenous fluids before epidural anesthesia is given in order to avoid this potential side effect. Epidural analgesia is sometimes called a walking medication, because it relieves pain but does not numb the body, thereby allowing movement. Combinations of medications may be used in an epidural part analgesic, part anesthetic. Postpartum headache may occur if the epidural needle enters the spinal canal rather than staying in the space around the canal.
The usual conventional X-ray examinations, including examination of the lower abdomen, all give a dose of less than 5 rem. In most cases, in a single X-ray of the abdominal, pelvic, and lumbar spine region (without shielding of the uterus), the dose will be well under 200 mrem, provided that examinations are conducted with current and correctly adjusted equipment. Longer screening times, as used in intestinal explorations or urographies, can lead to a dose to the uterus of 2 rem. Endoscopic retrograde cholangio-pancrcatography (ERCP) was evaluated in 17 pregnant women (Kahaleh 2004), and the mean fetal radiation exposure was 40-46 mrad (range 1-180 rnrad). Computerized tomography (CT scan) delivers higher doses however, these mostly stay below 5 rem. The secondary irradiation owing to examinations of other body regions, such as the upper abdomen, thorax, extremities or teeth, is negligible, because the doses delivered to the uterus lie well below 10 mrem - even as low as 1 mrem.
And lactation are causal or accidentally associated with the condition. It is equally unclear whether these osteoporotic fractures reflect architectural deterioration of a previously abnormal skeleton or whether pregnancy and lactation themselves account in large part for the bone loss and fragility fractures, situations that may be compounded by low calcium intake and vitamin D deficiency. As reviewed previously, skeletal demineralization normally occurs during lactation as a consequence of the actions of mammary gland-derived PTHrP in the setting of low estradiol levels and is not preventable by increased calcium intake osteoporotic fractures may occur in some women during lactation when the demineralization is excessive or the skeleton is unable to tolerate the normal lactational losses of mineral. PTHrP levels were high in one case of lactational osteoporosis and were found to remain elevated for months after weaning 89 . One study, which followed 13 women with...
This is the ideal position to go into labour. The baby's head and spine are flexed and the arms are crossed over the chest. In this position the fetus forms a complete ovoid, fitting nicely into the uterus head down. Records will note it as left occipito-anterior or right occipito-anterior depending on the position in which the baby is lying in the mother's pelvis. In this position the baby's spine is against the soft abdomen of the mother. When the head is flexed it presents the smallest diameter to pass through the pelvis, and normal labour is usual. With the head flexed and engaged in this position, it presses evenly on the cervix and good contractions are likely to ensue.
In contrast, in the occipito-posterior position, the baby's spine is aligned against the mother's spine. Flexion of the head is more difficult and if the head is not flexed, it has a more difficult job ahead entering the pelvic brim. The analogy is with an egg lying sideways in an eggcup. There is a risk in an OP position that the head will be deflexed (i.e. bent backwards at the neck) rather than forwards in the normal flexed position. This means that the smallest diameter of the head is not presented to the cervix. Contractions will not be as effective and dilation of the cervix is likely to be uneven because the head is not pressing tightly on the cervix.
You may want to ask for general or regional analgesia if you are having difficulty coping with pain during the second phase of stage-one labor. You will still feel contractions with systemic pain relief (usually delivered by IV or injection), but to a lesser extent. The medication might make you feel drowsy or dizzy, and you will not be allowed to walk around after receiving it. Generally, regional anesthesia (such as an epidural or spinal, or both) will provide more complete pain relief, although you might continue to feel some pressure if the baby is low in your pelvis.
The tests that will be ordered in the ER depend on your child's problem and the findings from the history and physical exam. A large array of tests and procedures are used in hospitals, including blood tests to detect infection and chemical imbalances, urine tests, spinal taps, cultures, X-rays, computerized tomography (CT) scans, magnetic resonance imaging (MRI), and others. Frequently, bone X-rays are ordered for injuries that result from a tumble. CT scans may be ordered for head injuries. Most of the time, however, the most effective way of diagnosing problems is with a careful history and physical examination. Lab tests often are used to confirm or exclude a suspected diagnosis.
Neural tube defects are a group of birth defects that affect the developing embryonic brain or spine and occur when the developing neural tube fails to close during the first 28 days of gestation 9 . The two most common NTDs are spina bifida and anencephaly, which can cause lifelong disability or death. Birth records collected through birth defect surveillance by the Center for Disease Control and Prevention (CDC) suggest that approximately 2,500 babies with NTDs, or 1 to 2 per 1,000, are born each year in the United States 10, 11 . The rate of NTD affected pregnancies is approximately 40 higher in women of Hispanic descent compared with Caucasian women 12 , while the rate in African American women is approximately 30 lower than in Caucasian women 11 .
Central nervous system disorders are among the three major causes of mortality in neonates. All of the conditions that affect the infant's brain do so in part because this system is developing at a rapid rate. The neurologic examination of the newborn must thus be interpreted in the context of the child's brain maturation (gestational age) and level of alertness. The examination should be brief so as to avoid hypoxemia and fluctuations in arterial blood pressure. Head circumference is a useful measure of intracranial volume, and longitudinal measurements in particular provide important information. Observation of movement and symmetry can contribute significantly to the evaluation while minimizing the effects of handling, especially in the sick neonate. These observations should include any available assessment of the fetus in the intrauterine environment. Examination of the following cranial nerves is possible 1 (olfaction) 2 (optic fundi) 3 (pupils) 3, 4, 6 (extraarticular...
In 1967 Shealy, a prominent neurophysiologist, considered that direct stimulation by TENS of the dorsal column of the spinal cord could inhibit the transmission of pain to the higher pain perception centres of the brain (Shealy et al 1967). The discovery in 1975 of morphine-like peptides known as endorphins (Hughes et al 1975) was followed closely by the discovery of opiate receptors distributed throughout the central nervous system and the release of endogenous opioid by acupuncture (Sjolund & Eriksson 1979). When released, endorphins travel and attach themselves to these receptors this action increases pain tolerance.
Endorphins Non-segmental and segmental effects small fibres act on three sites spine, brainstem and pituitary High intensity of some TENS devices activates small muscle (type III) nerves producing Deqi Pads placed on acupuncture points as these are over small-diameter afferent nerves (type III) in muscle Low frequency (1-4 Hz) produces no muscle spasm at high intensity and hence allows strong stimulation needed for Deqi Pulse trains cause muscle spasms at high intensity and do not permit adequate intensities for Deqi Analgesia has slow onset and long duration needs only 30 minutes of therapy for prolonged effects No tolerance from short, 30-minute treatments
There is a realignment of the spinal curvatures during pregnancy to maintain balance (see figure 5-3). It is due to the increase in size of the uterus and pressure on the abdominal wall. The patient walks with head and shoulders thrust backward and chest protruding outward to compensate. This gives the patient a waddling gait.
Level II scans are performed to evaluate pregnancies in which an abnormality is suspected or prenatal diagnosis is indicated. High-resolution ultrasonography has led to the rapid expansion of the number of diagnoses that can be made by indirect visual evaluation of the fetal anatomy. Abnormalities such as small facial clefts, polydactyly, and defects in the fetal spine can be visualized (52). Disproportionate growth can be readily assessed for the prenatal diagnosis of skeletal dysplasias (53). Filling and emptying of the fetal bladder in response to maternal diuretic ingestion can be used to assess the functional integrity of the fetal urinary tract. The need for amniocentesis has been the subject of ongoing debate when choroid plexus cysts are seen on ultrasonographic examination because of the association with trisomy (54). Generally, the finding of more than one anomaly increases the risk of a chromosome abnormality, in which case amniocentesis should be offered for cytogenetic...
This term infant shows massive head enlargement as the result of congenital hydrocephalus. This results from overproduction or obstruction of the circulation of the cerebrospinal fluid. It can be inherited as an X-linked recessive trait in a male infant as the result of aqueduc-tal stenosis. Other underlying brain defects may be present. Figure 3.28. This term infant shows massive head enlargement as the result of congenital hydrocephalus. This results from overproduction or obstruction of the circulation of the cerebrospinal fluid. It can be inherited as an X-linked recessive trait in a male infant as the result of aqueduc-tal stenosis. Other underlying brain defects may be present.
A midline hair tuft in the lum-bosacral area. This infant had a tethered cord on MRI study. Hair tufts, skin tags, sinuses, and abnormal pigmentation that occur in the midline along the length of the spinal column should always alert one to the possibility of an associated underlying neurologic abnormality. With a tethered cord the neural tissue is firmly attached at its caudal end, being bound by a stout connective tissue band to the interior of the bony canal. With growth, the spinal canal normally grows more rapidly than the spinal cord resulting in traction on the cord. This may gradually pull the lower end of the brainstem down into the foramen magnum like a cork into a bottle. This is the Arnold-Chiari malformation. Figure 3.58. A midline hair tuft in the lum-bosacral area. This infant had a tethered cord on MRI study. Hair tufts, skin tags, sinuses, and abnormal pigmentation that occur in the midline along the length of the spinal column should always alert one to...
The demonstration of elevated AFAFP levels greater than 3.0 standard deviations from the mean, or over 2.0 multiples of the median (MoM) for gestational age will detect 98 to 100 of fetuses with NTD. Errors in estimation of gestational age account for the majority of false-positive results and can be resolved by ultrasonographic reassessment of fetal measurements. Increased AFAFP levels are usually the result of exudation of fetal serum proteins through skin defects or across fetal membranes. This mechanism accounts for the elevated AFAFP in anencephaly, open spinal cord lesions, and ventral wall defects such as omphalocele and gastroschisis. Abnormal renal filtration of protein, as is found in the Finnish type of congenital nephrosis, also results in high AFAFP. Gastrointestinal obstruction or swallowing defects make it impossible for the fetus to reabsorb the AFP in the small intestine, thus resulting in polyhydramnios and elevated AFAFP. Twin gestations, missed abortion, impending...
In grade III, a large amount of blood in the ventricles causes the ventricles to enlarge, sometimes only temporarily. The body can slowly reabsorb the blood. However, the large amount of blood in the ventricles can block the flow of cerebrospinal fluid and interfere with the absorption of the cerebrospinal fluid around the brain. This leads to hydrocephalus, which means there is too much fluid in the ventricles. This extra fluid may cause the baby's head to grow more rapidly than normal and puts pressure on the baby's brain. The majority of infants with grade
Figure 14.5 Ultrasound scan showing Figure 14.6 Ultrasound scan of baby's spine. normal heart structures of baby. Figure 14.5 Ultrasound scan showing Figure 14.6 Ultrasound scan of baby's spine. normal heart structures of baby. the baby, for example in the heart, lungs, spine, brain, long bones in legs or arms, organs in the abdomen like liver, stomach, intestines, kidneys, bladder and even check for cleft lip and palate.
Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus. d. Station. This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother's pelvis. Measurement of the station is as follows (2) The ischial spines is the dividing line between plus and minus stations. (3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3). (4) The ischial spines is zero (0) station. (5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.
Folate is vitamin B, which is essential for cell division and organ formation. This nutrient helps prevent neural tube defects (malformations of the brain and spinal cord) in your developing baby and anemia in pregnant woman. Due to the severe nature of neural tube defects, we strongly advise adequate folate intake of at least 800 micrograms daily before conception and throughout the first three months of pregnancy.
In animal studies, COX-2 regulates the tone of the fetal ductus arteriosus and was present in the fetal kidney. As with classic NSAIDs, exposure during the third trimester may result in adverse cardiovascular and renal effects (Cuzzolin 2001, 0stensen 2001) and treatment around the time of conception may lead to fertility problems (Pall 2001). A recent study comparing valdecoxib and placebo could not demonstrate an advantage with respect to total analgesic consumption when used during cesarean section. The authors concluded that adding valdecoxib after cesarean delivery under spinal anesthesia with intrathecal morphine is not supported at this time (Carvalho 2006).
A poor glyccmic control in prcgestational diabetes, as measured by glycosylated hemoglobin (HbAlc 6.5 ), is correlated with an increased risk of major congenital malformations. HbAlc is a parameter for the blood glucose concentration of the last 120 days, the survival time of erythrocytes it can also be referred to as the blood sugar memory . The higher the concentration of HbAlc, the higher the statistically confirmed rate of malformations an HbAlc of 8.5 is correlated with a malformation rate of 4 an HbAlc of 10.5 has a risk for abnormalities of 6 . The most common birth defects are anomalies of the spine and extremities, of the heart and circulatory system, and neural tube defects. Urogenital defects, gastrointestinal fistulas, and atresias arc seen more seldom (for an overview, see Briggs 2005, Loffredo 2001).
The spinal cord is composed of nerve cells of grey matter, which relay these pain signals to the brain, and nerve axons of white matter. It runs inside the vertebral column, branching out in pairs through openings called intervertebral foramina. There are over 30 such pairs of spinal nerves, named according to their source for example, cervical nerves arise from the neck and thoracic nerves from the thorax. Bonica (1994) reported that nerves T10, T11, T12 and L1 (corresponding to the respective thoracic and lumbar vertebrae) supply the lower segment of the uterus and the cervix (although this is contradicted by some texts that consider that the cervix is supplied by sacral nerves). Labour pain is felt over the areas of the back (dermatomes), which are supplied from these spinal nerves. In the first stage of labour the area affected relates to T11 and T12.
This is when the presenting part is at the level of the ischial spines or at a zero (0) station. Before this time, it is referred as floating. (5) Extension. As the previously flexed head slips out from under the pubic bone, the fetus is forced to extend his head so that the head is born pushing upward out of the vaginal canal. The natural curve of the lower pelvis and the baby's head being pushed outward forces distention of the perineum and vagina. As it moves through the vaginal canal, the chin lifts up (extends) and the head is delivered. During this maneuver, the fetal spine is no longer flexed, but extends to accommodate the body to the contour of the birth canal.
Need for medications (Beck et al. 1979 Klerman et al. 1984 Spinelli 1997). In general, pharmacologic treatment is pursued when non-pharmacologic strategies have failed or when it is felt that the risks associated with psychiatric illness during pregnancy outweigh the risks of fetal exposure to a particular medication. IPT is a short-term, manual-driven psychotherapy that deals primarily with four major problem areas grief, interpersonal disputes, role transitions, and interpersonal deficits (Keller et al. 1984). Given the importance of interpersonal relationships in couples expecting a child and the significant role transitions that take place during pregnancy and subsequent to delivery, IPT is ideally suited for the treatment of depressed pregnant women. Spinelli has adapted IPT for the treatment of women with antenatal depression, focusing on the role transitions and interpersonal disputes characteristic of pregnancy and motherhood. in a pilot study of 13 women (Spinelli 1997), IPT...
Folic acid is a B vitamin that h elps prevent birth defects of the spinal cord and br ain called neural tube defects (NTDs see page 5 9), which result in spina bifida and anencephaly. NTDs happen in the first month of pregnancy, so you need to make sure you h ave enough folic acid in your system before you conceive. Start taking folic acid when trying to conceive and continue throughout pregnancy bee ause levels drop i n th e second an d th ird trimesters due to changes in your blood folate level.
Premature babies are at risk for infection because they have an immature immune system. Often your baby's doctor will obtain samples of blood, urine, and spinal fluid for analysis to help detect infection in your infant. If an infection is found, it will be treated with medication. Common infections in premature babies include these
And occur in 2 to 3 of all live births. The incidence is estimated to be 4 to 8 for women with epilepsy who are taking one AED, and possibly greater for women taking more than one AED. The types of major malformations that occur most often in children of women with epilepsy are facial clefts, cardiac abnormalities, and neural tube (spine and brain) defects.
Of the high-risk medications, only valproate is likely to be taken by women of childbearing age. Doctors might try to remove valproate if there is a family or previous history of spina bifida (a neural tube birth defect in which the bones of the spine do not form properly around the spinal cord). The present medical policy is to avoid using this drug in women of childbearing potential unless it is the only drug that will help them. Valproate is often, but not always, withdrawn, or lamotrigine is substituted. Withdrawal or substitution is a long, slow process, however. If it is impossible to completely withdraw from valproate, physicians often reduce the dose as much as possible, and suggest it be taken 3 to 4 times a day. The hope is that spreading out the dose in this way will reduce the risk of seizures.
Achondroplasia (rhizomelic dwarfism). This is dominantly inherited but many cases occur by spontaneous mutation. There are short proximal parts of the arms and legs (rhizomelic micromelia), marked lordosis, caudal narrowing of the spine, and spade-like hands (short trident hand with short metacarpals and phalanges). Note the normally sized but laterally compressed trunk. Figure 2.1. Achondroplasia (rhizomelic dwarfism). This is dominantly inherited but many cases occur by spontaneous mutation. There are short proximal parts of the arms and legs (rhizomelic micromelia), marked lordosis, caudal narrowing of the spine, and spade-like hands (short trident hand with short metacarpals and phalanges). Note the normally sized but laterally compressed trunk. In hypochondroplasia syndrome there is a near normal craniofacies but the limbs are short and there is caudal narrowing of the spine. In hypochondroplasia syndrome there is a near normal craniofacies but the limbs are short and...
Scans may also be obtained during the second and third trimesters to assess fetal age, growth, position, and sometimes gender identify congenital malformations of the face, brain, spinal column, heart and other internal organs, and the limbs exclude multiple pregnancies and evaluate the placenta, amniotic fluid, and remaining structures of the pelvis.
During pregnancy at 15-20 days gestation, GK rats had gained less weight than controls, though the number of fetuses in each litter was similar. The abortive fetal development averaged 40 compared with 6 in controls. A particular finding was the low number of ossification points in the lumbosacral spine, pelvic girdle, and anterior and posterior limbs (Figure 12.5).99 These anomalies were not related to lower plasma insulin levels before or during the pregnancy and may be related to the impaired vitamin D metabolism in the GK rats.100
Folic acid deficiency has been linked to defects such as spina bifida, a condition where the spinal cord does not develop properly. Mothers who supplement folic acid and vitamin B12 before conception and during the first 3 months of pregnancy have a lower incidence of neural tube defects. A survey of 23 000 women found that those who supplemented their diet in the first 6 weeks of pregnancy had a 75 lower incidence of neural tube defects than those who did not (DOH 1992). Folic acid in food is destroyed by sunlight, heat and an acid environment, and the use of antibiotics also leads to deficiency. Supplementation of 400 lg a day is recommended from before conception up until the end of the first trimester (DOH 1992, Smithells 1983). This can be obtained on prescription but unless a woman qualifies for free prescriptions, it may be cheaper to buy it at a supermarket or pharmacy. Good food sources include green leafy vegetables, brewer's yeast, wholegrains, wheatgerm, milk, salmon, root...
Cell division occurs in the blastocyst, distinguishing placental cells from embryonic cells. At the same time, each individual cell is directed so that it has a specific function, such as a liver cell or a heart cell. Once it is programmed it cannot change into another type of cell. Within the embryonic cell cluster, a disk forms, which in turn develops three layers. The outermost layer becomes the brain, spinal cord, nerves, parts of the eyes and ears, skin, h air, nails, and tooth enamel. The cells in the middle layer develop into the skeleton, h eart and other muscles, cartilage and connective tissue, blood cells and vessels, lymph cells and vessels, reproductive organs, At day 15 after conception, nerve cells begin to form the brain and spinal column, and the brain sp arks into action . Your blood volume increases to cope with the extra demand for oxygen.
First-line treatment, even with the largest adenomas, is with DA agonists. These induce falls in prolactin concentrations within 24 hours and tumour shrinkage within weeks. These improvements continue with duration of treatment. The visual field defects usually recede, and PRL concentrations return to normal in 58 of cases. Rapid shrinkage may result in a leak of cerebrospinal fluid from the nose (CSF rhinorrhoea).
The brain and spinal cord develop from an embryonic structure called the neural tube. This begin s as a tiny ri bbon of ti ssue th at folds i nward to form a tube by the 28th day after fertilization. When the neural tube does not close completely, defects in th e br ain and spi n al cord may occur. Some 300,000 babies are born with neural tube defects ( NTDs) in the world every year, while other affected pregnancies end in miscarriage or stillbirth. The most common NTDs are spina bifida and an enceph aly ( abse nce of a br ai n) .
Symptoms usually occur between 4-7 months of pregnancy4. Pain is usually low in the back, sometimes radiating into the buttocks and thighs, and occasionally down the legs as sciatica. There is also a great variation in the severity of symptoms between individuals. Some women have transitory stiffness or discomfort, whilst others are severely affected4. The pain is usually exacerbated by prolonged standing or sitting, forward bending and lifting. Some women also experience pain over the symphysis pubis or thoracic spine at the same time. Associated factors include5
A more clinically relevant definition of osteoporosis is made on bone mineral density measurement (BMD). BMD is usually measured at the lumbar spine, hip and the radius. Results are expressed in grams per centimetres squared (g cm2) as an area density expressed as standard deviations related to the BMD of young adults (T-score). Results can be expressed as standard deviation related to age this constitutes the Z-score. The WHO diagnostic classification is These criteria strictly apply to women, and at the sites of measurement of hip, spine and forearm.
A longitudinal study up to the age of 9 years, covering 198 mother-child pairs, indicated that vitamin D deficiency in late pregnancy may lead to significantly reduced ossification of the whole skeleton, and in particular of the lower spine. A lower than normal calcium concentration in the cord blood may also predict poorer ossification (Javaid 2006).
Often accompanying head injuries, neck injuries can be just as serious and call for extreme caution on the part of any care-giver. If the child is unconscious, assume there could be a neck injury. Moving the head or neck of a child who has a broken bone in the neck can damage the spinal cord, causing paralysis or even death. For this reason, you must not move a child with a suspected neck injury without the help of medical personnel, unless the child's life is in immediate danger.
She was experiencing quite a lot of back ache, even though the baby was in the correct OA position. So, still keeping the needles in her ears and with her still straddling the chair, I asked her to point to where the back ache was most intense. Using the second output on my machine, I put two pads low down on either side of her spine, keeping the same frequency on the machine. Her waters were still intact (this is always preferable, as I feel women suffer far less pain when the membrane is allowed to rupture naturally). As part of my duties as a midwife, I recorded her partogram (labour chart) and checked that she had passed urine, enabling the baby's head to descend. She was still happy to chat and eat and drink. Her back ache was quite severe during contractions but she seemed to be coping well with the pain, sitting on the chair during each contraction.
This infant at age 5 days developed fever, lethargy and poor feeding. On sepsis evaluation there was a pleocytosis of 120 WBCs in the cerebrospinal fluid indicative of meningoen-cephalitis. There was no evidence of cardiac involvement. The following day the infant developed a generalized maculopapular rash and loose stools. He recovered without treatment. Stool culture grew Coxsackie virus. Figure 2.89. This infant at age 5 days developed fever, lethargy and poor feeding. On sepsis evaluation there was a pleocytosis of 120 WBCs in the cerebrospinal fluid indicative of meningoen-cephalitis. There was no evidence of cardiac involvement. The following day the infant developed a generalized maculopapular rash and loose stools. He recovered without treatment. Stool culture grew Coxsackie virus.
Radiograph of the same infant with inien-cephaly. Note absence of the laminal and spinal processes of the cervical, dorsal, and sometimes lumbar vertebrae. The vertebrae are reduced in number and are irregularly fused. Figure 3.31. Iniencephaly is the most severe form of a closed neural tube defect. It results in enlargement of the foramen magnum and fusion of the posterior occiput with the cervicothoracic spine. It is incompatible with survival. Figure 3.32. Radiograph of the same infant with inien-cephaly. Note absence of the laminal and spinal processes of the cervical, dorsal, and sometimes lumbar vertebrae. The vertebrae are reduced in number and are irregularly fused. Figure 3.33. Another infant with iniencephaly showing the lack of a neck due to the fusion of the posterior occiput with the cervicothoracic spine.
The most severe form is presumably the consequence of a wedge-shaped early deficit of the caudal blastema.45 Associated anomalies, in accordance with the severity of the syndrome, may include imperforate anus, absence of external genitalia, renal agenesis, absence of internal genitalia except gonads, a single umbilical artery, absence of bladder, and fusion of the lower limbs. The principal findings of caudal regression syndrome on sonographic radiology are as follows various types of lower limb anomalies ranging from hip dislocation to frog-leg deformity and equinovarus, hydrocephalus, and Dandy-Walker malformation, complete absence of the spine below L , partial or complete absence of the caudal part of the sacrum, intraspinal anomalies in the form of meningomyelocele and sacral lipoma, whereas the pelvis is small owing to the absence of a sacrum, and the iliac bones touch or even fuse.46 Up to 16 of these cases are associated with diabetes mellitus.47,48 Although the disorder...
Complications In rare cases, HSV-1 can cause meningitis, an inflammation of the membrane covering the brain and spinal cord. It is the most common cause of fatal sporadic encephalitis, an inflammation of the brain (see Encephalitis in this chapter). A mother with genital herpes can pass on the infection to her newborn, causing a severe, potentially fatal infection in the infant's central nervous system.
Cause An inflammation of the meninges, the membrane covering the brain and spinal cord, meningitis can be caused by bacteria, viruses, fungi, or parasites that enter into the cerebrospinal fluid from the blood. Streptococcus pneumoniae, Neisseria meningi-tidis, and Hemophilus influenzae type B are the most common bacteria causing the infection in children. Enteroviruses are the most frequent viral cause. Bacterial infections are generally more serious than viral defects of the meninges and are potentially life-threatening. Incubation Period This varies with the organism. For enteroviruses, the incubation period is 3 to 6 days other viruses may range from 4 to 21 days. Once the infection has entered the spinal fluid, symptoms usually occur rapidly. How the Diagnosis Is Made A lumbar puncture, or spinal tap, is performed to examine the spinal fluid. Blood and urine tests may also be done.
Symptoms Joint pain, fever, and fatigue are the most common first symptoms . One or more joints, particularly wrists, elbows, knees, or ankles, may become painful, red, warm, and swollen. Heart inflammation (carditis) may start at the same time as the joint pain, but there may be no symptoms of this at first. The doctor may hear a heart murmur (abnormal heart sound) through a stethoscope. The heart may beat rapidly, and the sac around the heart may become inflamed, causing chest pain. Heart failure may develop, the symptoms of which can include shortness of breath, nausea, vomiting, stomachache, and hacking cough. In some cases the child may also develop abnormal involuntary body movements, a rash, and painless bumps under the skin, usually on the knees, elbows, and spine.
How the Diagnosis Is Made Lab tests can be done to check for parasites in the blood, spinal fluid, lymph nodes, bone marrow, amniotic fluid, and placenta of a pregnant woman. The doctor may order blood tests to check for levels of antibodies, part of the body's immune reaction to the parasite. Tests such as PCR (polymerase chain reaction) can be used to identify the DNA of the parasites.
Hydrocephalus (also known as water on the brain ) is a central nervous system disorder that can cause enlargement of the head in newborns and infants, brain damage, and neurological problems. Hydro-cephalus is characterized by an excessive accumulation of cerebrospinal fluid (CSF) in the brain. Normally, CSF (which protects the brain and spinal cord by acting as a cushion) flows through the central nervous system much like oil flows through a car's engine. A membrane in the brain produces CSF, which travels down the spinal cord and back again to the brain, where structures in the brain reabsorb it. Under normal circumstances, this flow pattern keeps a healthy amount of CSF surrounding the brain and spinal cord. If the brain does not properly reabsorb the CSF or something in the brain blocks the normal CSF flow, the amount of CSF and the pressure within the head increase, which may damage brain tissue and result in hydrocephalus.
In KK Hospital, devices are available that allow the mother to self-administer short-acting opioid medication into the blood stream intravenously by pressing a button (a technique known as 'Patient-Controlled Intravenous Analgesia' or PCIA). This is particularly useful as an alternative for pain relief in situations when epidural analgesia cannot be administered, such as in mothers with bleeding tendencies such as low platelet levels or spinal problems such as prolapsed intervertebral discs. The Combined Spinal-Epidural Analgesia (CSEA) differs from EA in that an initial dose of drug is given into the spinal space, which is also within the backbone canal. This results in a faster onset of pain relief. The decision for EA or CSEA is usually left to the discretion of the anesthetist, as dictated by the stage and progress of labor.
Computed tomography (CT) delivers doses of radiation that can range from approximately 5 rad to the skin to 2 rad in the center of the slice. Maximal fetal doses of radiation from CT studies of the head and chest are minimal, but studies of the abdomen and lumbar spine can range from 2.6 to 3.5 rad, depending on gestational age
This infant has a thoracic myelo-meningocele which presents as an open midline defect. Although myelomeningoceles occur most commonly at the lumbosacral level, they may affect the neural tube at any level. The posterior elements covering the spinal canal fail to form, but in this type of defect the cystic mass that bulges out posteriorly contains neural tissue and the surface of the meninges is exposed to the exterior with no skin covering. Large lesions may incorporate a large segment of the spinal cord itself. Figure 3.65. Thoracolumbosacral myelo-meningocele with exposure of the central spinal canal. Note the leaking of cerebrospinal fluid. The meningeal sac often ruptures before birth or during delivery, thus exposing the neural tissue to direct injury or the risk of infection. Loss of neurologic function distal to the lesion is the rule. There may be absence of control of the urinary and anal sphincters, bladder paralysis, and variable degrees of sensory and motor...
Osteoporosis associated with pregnancy Vertebral collapse presenting for the first time in pregnancy is rare and making the diagnosis is all important. Characteristically, vertebral collapse occurs in the third trimester but may occur any time until after delivery. Sudden, severe back pain in the thoracic and or lumbar spinal region, persisting for some weeks or even months, are the main clinical features. Lateral spinal X-rays showing vertebral collapse would be diagnostic, and careful judgement would be needed about the need to do these as there is a relative contraindication If the diagnosis has not been confirmed then lateral spinal X-rays and bone mineral density investigations will be needed If no cause is found, recurrence of spinal osteoporosis is not usual but osteoporosis of the hip can recur. Careful review and advice will need to be given.
How the Diagnosis Is Made Your child's doctor may order blood tests and perform a spinal tap (lumbar puncture) to examine spinal fluid for evidence of infection. An EEG (electroencephalogram), which measures brain waves, and either an MRI or CT scan, which looks for swelling and other changes in the brain, may also be done.
How the Diagnosis Is Made There is no single diagnostic test, but your child's doctor will check liver function with blood tests, and he or she may order a CT scan or MRI if he or she suspects brain swelling. A spinal tap (lumbar puncture) may be performed to rule out other conditions affecting brain function.
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