Friday, 27 April 2018

Post Partum Blues, Depression and Psychosis




Post partum Blues

  • Occurs in around 50% of the women
  • Around 4th to 5th PPD
  • Usually self limiting though in rare circumstances progresses to postnatal depression.
  • Cure by support of medical practitioner is all that is required



Post natal depression


  • Onset at around 4th week PP 
  • Lasting for around 6 months
  • Family H/O mental disorder is usually present.
  • C/F are that of sleep disturbance, depression, social withdrawal, lack of worthiness of being a mother, suicidal thoughts, concern that she may harm her child
  • Management- Social support, refd to psychiatrist



Puerperal Psychosis


  • Occurs in 0.2% of the mothers
  • Onset is earlier than the postnatal depression
  • The chance that a mother may harm her baby is very high.
  • Serious condition the requires an expert psychiatric evaluation and treatment

Breast Complications




Common breast complications are

1.Breast engorgement
2.Cracked & retracted nipples
3.Mastitis and breast abscess
4.Failing lactation

Breast engorgement
  • Due to exaggerated normal venous & lymphatic engorgement preceding lactation, preventing escape of milk from lacteal systm.
  • Manifest after the milk secretion- 3rd -4th PPD
  • S/S- Pain, feeling of tenseness and heaviness in both breast, malaise, ↑tempt
  • Treatment-Support breast with binder & brassiere, ice bag, express milk or frequent breast feeding, analgesic
  • Prevention- Manual expression of the remaining milk & frequent breast feedings

Cracked Nipple
  • Due to a) loss of surface epithelium, causing a raw area b) fissure at the tip or base of nipple
  • Caused by 1)unhygiene –crust over the nipple 2) retracted nipple 3) vigorous suckling
  • Asymptomatic usually but if infection, it is painful due to mastitis
  • Treatment-keep nipple clean & dry, nipple shield during each feed, rest if worst and feed by expression, antibiotics ( oral & applicant)  and analgesic
  • Prevention-Local cleanliness during pregn and puerperium

Retracted nipple
  • Primigravida
  • If left uncorrected may predispose to cracked nipple- difficulty in breast feeding
  • Manual lifting of the retracted nipple during pregnancy is advisable.
  • After delivery, use of nipple shield is advisable.

Acute Mastitis

Mode of infection


2 different types of mastitis

  • Infection follows a cracked nipple to involve the breast parenchymal tissues leading to cellulites.
  • Infection gains access through the lactiferous duct leading to development of primary mammary adenitis
  • Responsible organism is Staph aureus- infection comes from nasopharynx of the baby.

Clinical feature
  • Symptom- Generalised malaise, headache, fever with chills
  • Severe pain and tender, swelling in 1 quadrant of the breast.
  • Sign- Wedge shaped swelling on the breast with the apex at the nipple
  •  Over lying skin is hot, flushed, tense and tender

Treatment

  • Antibiotics- Cloxacillin, Cefalosporin
  • Analgesic 
  • Antenatal-Wash the nipple periodically to keep the patency of the duct opening.
  •  Breast feeding on the affected is suspended
  • Manual expression & prevention of engorgement of breast.

Breast Abscess
  • Swinging tempt
  • Reddened breast
  • Marked tenderness with fluctuation.

Treatment
  • Antibiotics
  • Incision and drainage

Wound infection
  • Wound can be that of a CS or an episiotomy wound
  • Infection in the wound usually develops around the 5th to 6th POD
  • Take Swab from the wound and send for C/S 
  • Treat with antibiotics and daily dressing
  • Followed by secondary suture,

Chest infections
  • Usually following general anaesthesia in CS
  • Take x-ray chest and sputum for C/S
  • Treatment is with physiotherapy, warm saline gurgle, steam inhalation and antibiotics

Deep Vein Thrombosis (DVT)
  • Usually occurs at around 7-10th PPD
  • Begins in the deep veins of the calf or soles of the feet and extend upwards
  • Often symptomless
  • Sharp dorsiflexion of the foot elicit pain in the calf-Homan’s sign
  • Slight rise of tempt & pulse.
  • These early S/S may be missed and detected only when pulmonary embolism has developed or when the generalised oedema of the leg has set.
  • Exercise in early puerperium is beneficial.
  • The foot end of the bed is elevated to increase the venous flow from the leg.
  • Antibiotics to prevent infection
  • Anticoagulant to prevent clot formation-Heparin.
  • After being afebrile the pt is encouraged to walk about with the affected leg supported by elastic bandage.

Puerperium

Definition

Normal puerperium
  1. The time from the delivery of the placenta through the first few weeks after the delivery
  2. 6 weeks in duration. 
  3. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.

The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment. 

Abnormal Puerperium

  • Puerperal Pyrexia
  • postnatal psychosis and depression

Puerperal Pyrexia

Definition

P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.

Cause of P. Pyrexia
  1. P. Sepsis- Genital tract infection
  2. UTI
  3. Breast Complications
  4. Wound Infections
  5. Thrombophlebitis and DVT
  6. Respiratory infections

Puerperal Sepsis

Definition

An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

Vaginal flora
  1. L bacillus ( 60-70%)
  2. Yeast like fungus- Candida albicans ( 25%)
  3. Staph albus or aureus
  4. Strepto β haemolyticus
  5. E coli and bacteroids
  6. Cl welchii-rare


These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions. 

Predisposing factors to P Sepsis


  1. Conditions lowering the resistance 
  2. Malnutrition & anaemia
  3. PROM
  4. Chronic debilitating diseases
  5. Repeated PV examination after rupture membrane
  6. Traumatic manipulative & operative delivery
  7. Haemorrhage 
  8. RPOC- retained product of conception
  9. Placenta previa




Organism responsible for P sepsis
  • Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto, 

  • Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani

Pathology and the primary site of infection

Uterus

Endomyometritis- is the most common and usually mildest form of genital infection.

4 Classical signs:
  • Pyrexia 37.8-38o C
  • Pulse 100-120
  • Fundal height- not decreasing
  • Lochia red &offensive smell


Clinical examination & Daily Charting

Investigations

  1. High vaginal smear and endocervical swab for C/S
  2. MSU for R/M/E & C/S
  3. Blood for Hb,TC, DC & C/S
  4. Blood for MP
  5. Widal Test
  6. X-ray chest


Treatment 

1.Adequate fluids, rest and movement of bowel- Milk of magnesia
2.Correction of anaemia
3.Antibiotics- Broad spectrum
        I/V Ampicillin 500mg  6 hrly
        I/V Metronidazole 500 mg  8 hrly
        I/V Gentamycin  3-5 mg/kg body wt in divide dose
                                    OR
        I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly
                    Change according to C/S             

Urinary tract infection
  • Incidence is 1-5%
  • Organisms- E coli, klebsiella, Proteus, Staph aureus
  • Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic, 
  • Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
  • Investigation- Urine for R/M/E and C/S
  • Treatment -Antibiotics

Causes of retention urine in puerperium

1.Bruising and oedema of the bladder neck
2.Reflex from the perineal injury
3.Unaccustomed position
4.Haematoma

Treatment
  • General measures
  • Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
  • Antibiotics

Cell components


NUCLEUS


  • The nucleus  is the site of deoxyribonucleic acid (DNA) replication and transcription of DNA into precursor ribonucleic acid (RNA) molecules. 
  • It contains all of the enzymes required for replication and repair of newly synthesized DNA, as wel as for transcription and processing of precursor RNA molecules. 
  • It is enclosed by the nuclear envelope and contains the nuclear lamina, nucleolus, and chromatin.

Nuclear Envelope

  • The nuclear envelope is a double membrane containing pores that are approximately 90nm in diameter. The outer nuclear membrane is continuous with the endoplasmic reticulum.

Nuclear lamina

  • The nuclear lamina is a lattice like network of proteins that include lamins. 
  • Lamins attach chromatin to the inner membrane of the nuclear envelope and participate in the breakdown and reformation of the nuclear envelope during the cell cycle
  • Phosphorylation of the lamina (by lamin kinase) during prophase of mitosis initiates nuclear disassembly into small vesicles.



Nucleolus

  • The nucleolus is responsible for ribosomal RNA (rRNA) synthesis and ribosome assembly.
  • It contains three morphologically distinct zones:
  • Granular zone-found at the periphery; contains ribosomal precursor particles in various stages of assembly.
  • Fibrillar zone-centrally located; contains ribonuclear protein fibrils.
  • Fibrillar center-contains DNA that is not being transcribed.


Chromatin

  • Chromatin is a complex of DNA, histone proteins, and nonhistone proteins.
  • DNA-a double-stranded helical molecule that carries the genetic information of the cell. It exists in three conformations: B DNA,Z DNA, and A DNA.
  • Histone proteins-positively charged proteins enriched with lysine and arginine residues. They are important in forming two types of structures in chromatin: nucleosomes and solenoid fibers. 
  • The nucleosomes are the basic repeating units of the chromatin fiber, having a diameter of approximately 10 nm.
  • Nonhistone proteins-include enzymes involved in nuclear functions such as replication, transcription, DNA repair, and regulation of chromatin function. They are acidic or neutral proteins.

Forms of chromatin
  • Heterochromatin-highly condensed (30-nm solenoid fibers or higher states of condensation) and transcriptionally inactive. In a typical eukaryotic cell, approximately 10% of the chromatin is heterochromatin. Almost the entire inactive X chromosome (Barr body) in each somatic cell in a woman is condensed into heterochromatin.
  • Euchromatin---,a more extended form of DNA,which is potentially transcriptionally active. In a typical cell, euchromatin accounts for approximately 90% of the total chromatin, although only about 10% is being actively transcribed in the 10-nm fiber of nucleosomes.



CYTOPLASM

Ribosomes

  • Ribosomesare composed of rRNA and protein. They consist of large (60S)and small (405) subunits.
  • Ribosomes are assembled in the nucleus and transported to the cytoplasm through the nuclear pores. The large ribosomal subunits are synthesized in the nucleolus, whereas the small subunits are synthesized in the nucleus. 
  • Polysomes-Ribosomes often form polysomes, which consist of a single messenger RNA (mRNA) that is being translated by several ribosomes at the same time. The ribosomes move on the mRNA from the 5' end toward the 3' end. The two ribosomal subunits associate on the mRNA, with the small subunit binding first.


Forms of ribosomes


  • Ribosomes exist in two forms:
  • Free polysomes are the site of synthesis for proteins destined for the nucleus, peroxisomes, or mitochondria. 
  • Membrane-associated polysomes are the site of synthesis of secretory proteins, membrane proteins, and lysosomal enzymes.



Endoplasmic Reticulum

The endoplasmic reticulum exists in two forms, rough endoplasmic reticulum (RER) and smooth endoplasmic reticulum (SER).

Rough endoplasmic reticulum

RER is a single, lipid bilayer continuous with the outer nuclear membrane. It is organized into stacks of large flattened sacs called cisternae that are studded with ribosomes on the cytoplasmic side.
RER synthesizes proteins that are destined for the Golgi apparatus, secretion, the plasma membrane, and lysosomes. RER is very prominent in cells that are specializedin the synthesis of proteins destined for secretion (e.g., pancreatic acinar cells).

Smooth endoplasmic reticulum

SER is a network of membranous sacs,vesicles, and tubules continuous with the RER, but lacking ribosomes.
SER contains enzymes involved in the biosynthesis of phospholipids, triglycerides, and sterols.


Functions of SER

Detoxification Reactions

These are reactions that make compounds water soluble so that they can be excreted. Two types of reactions that increase solubility are:

Hydroxylation reactions-by way of hydroxylase complexes containing cytochrome P450, a flavoprotein, and a nonheme iron protein

Conjugation reactions-the transfer of polar groups (i.e., glucuronic acid) from the active carrier UDPglucuronic acid to the toxic water-insoluble molecule

Steroid synthesis
  • Glycogen Degradation and Gluconeogenesis

Removal of the phosphate group from glucose-6-phosphate by the enzyme glucose-6 phosphatase, an integral membrane protein of the SER. This controls the formation of free glucose from glycogen and via gluconeogenesis.

  • Reactions in Lipid Metabolism

Lipolysis begins in the SER with the release of a fatty acid from triglyceride. The SER is also the site where lipoprotein particles are assembled

  • Sequestration and Release of Calcium Ions

In striated muscle the SER is known as the sarcoplasmic reticulum (SR).The sequestration and release of calcium ions takes place in the SR.


Golgi Apparatus

The Golgi apparatus consists of disc-shaped smooth cisternae that are assembled In stacks (dictyosomes), having a diameter of approximately 1micro.m and associated with numerous small membrane-bound vesicles.
The Golgi apparatus has two distinct faces:
The cis (forming) face is associated with the RER.
The trans (maturing) face is often oriented toward the plasma membrane.
The transmost region is a network of tubular structures known asthe trans-Golgi network (TGN)

Functions of the golgi apparatus

Proteins and Lipids
The Golgi apparatus is the site of post translational modification and sorting of newly synthesized proteins and lipids.
Glycoproteins
Further modification of the carbohydrate moiety of glycoproteins produces complex and hybrid oligosaccharide chains. This determines which proteins remain in the Golgi apparatus or leave the Golgi apparatus to become secretory proteins, lysosomal proteins, or part of the plasma membrane. Two diseasesare caused by a breakdown in this process,I-cell disease and
hyperproinsulinemia .


I-Cell Disease


  • Phosphorylation of mannose in glycoprotein targets proteins to Iysosome. Phosphate is addedin a two-step sequence of reactions that are catalyzed by N-acetylglucosamine-phosphotransferase and N-acetylglucosaminidases.
  • A deficiency in N-acetylglucosamine-phosphotransferases  results in I-cell disease(mucolipidosis II),in which a whole family of enzyme is sent to the wrong destination. It is characterized by huge inclusion bodies in cells caused by the accumulation of undegraded glycoconjugates in Iysosomes missing the hydrolase that normally degrade these macromolecules. The missing enzymes are found in the plasma and other body fluids, where they have normal levels of activity. The absenceof the mannose-6-phosphotase  on the hydrolase results in their secretion rather than their incorporation into Iysosomes.
  • The disease results in skeletal abnormalities,coarse features, restricted joint movements, and psychomotor retardation. Symptoms are generally noted at birth, and the life span is less than 10 years.
  • A somewhat less severe form of the disease with a later onset and potential survival into adulthood is called pseudo-Hurler polydystrophy.
  • There is no treatment for either disease, but prenatal diagnosis is available.

Hyperproinsulinemisia

Characterized by elevated levels of proinsulin in the serum resulting from the failure of a peptidase to cleave proinsulin to insulin and C- peptide in the Golgi apparatus.
The clinical manifestations are similar to those seen in patients with noninsulin dependent diabetes.


Lysosomes

Lysosomes are spherical membrane-enclosed organelles that are approximately 0.5 micro.m in diameter and contain enzymes required for intracellular digestion.

Lysosomes consist of two forms:

  • Primary Iysosomes have not yet acquired the materials to be digested. They are formed by budding from the trans side of the Golgi apparatus.
  • Secondary Iysosomes are formed by the fusion of the primary lysosome with the substrate to be degraded and have contents that are in various stages of degradation.
  • Lysosomes contain approximately 60 hydrolytic enzymes. These include nucleases for degrading DNA and RNA, lipases for degrading lipids, glycosidases for degrading glycoconjugates (glycoproteins, proteoglycans, and glycolipids), proteases and peptidases for degrading proteins, and a variety of phosphatases. . All lysosomal enzymes are acid hydrolases, with optimal activity at a pH of approximately 5.0.
  • The synthesis of the lysosomal hydrolases occurs in the RER; the hydrolases are transferred to the Golgi apparatus, where they are modified and packaged into lysosomes.



Peroxisomes


  • Peroxisomes are a heterogeneous group of small, spherical organelles with a single membrane and a diameter that ranges from approximately 0.15 to 0.5 micro.m.
  • Peroxisomes contain a number of enzymes that transfer hydrogen atoms from organic substrates (urate, D-amino acids, and very long chain fatty acids) to molecular oxygen with the formation of hydrogen peroxide. Catalase, the major peroxisomal protein, degrades the hydrogen peroxide to water and oxygen.
  • Peroxisomal enzymes are synthesized on free polysomes. After translation, the enzymes are incorporated directly into peroxisomes.


Peroxisomes have several functions:


  • Synthesis and degradation of hydrogen peroxide . 
  • Beta-0xidation of very long chain fatty acids (>C24) starts in the peroxisome and proceeds until the carbon chain has been reduced to a length of approximately 10carbons. Oxidation of the residual 10 carbons is completed in the mitochondria.
  • Phospholipid exchange-peroxisomes contain enzymes that convert phosphatidylserineand phosphatidylethanolamine.
  • Bile acid synthesis


Peroxisome Deficiency

Several genetic diseases are associated with the impairment or absence of peroxisomes. These patients fail to oxidize very long chain fatty acids and accumulate bile acid precursor.The four most common disorders are:

  • Zellweger (cerebrohepatorenal) syndrome
  • Neonatal adrenoleukodystrophy
  • Infantile Refsum disease
  • Hyperpipecolatemia



Mitochondria

Mitochondria have two membranes. They are about 0.5 micro.m in width and vary in length from 1 to 10 micro.m. They synthesize adenosine triphosphate (ATP), contain their own double-stranded circular DNA, and make some of their own proteins.
Mitochondria have several compartments.

Outer membrane


  • The outer membrane is smooth, continuous, and highly permeable. It contains an abundance of porin, an integral membrane protein that forms channels in the outer membrane through which molecules of less than 10kD can pass.


Inner membrane


  • The inner membrane is impermeable to most small ions (Na+, K+, H+) and small molecules (ATP, adenosine diphosphate, pyruvate). The impermeability is likely related to the high content of the lipid cardiolipin.
  • The inner membrane has numerous infoldings, called cristae. The cristae greatly increase the total surface area. They contain the enzymes for electron transport and oxidative phosphorylation.
  • The number of mitochondria and the number of cristae per mitochondrion are proportional to the metabolic activity of the cells in which they reside.


Intermembrane compartment

The intermembrane compartment is the space between the inner and outer membranes. It contains enzymes that use ATP to phosphorylate other nucleotides (creatine phosphokinase and adenylate kinase).


Matrix

The matrix is enclosed by the inner membrane and contains:
  • Dehydrogenases-oxidize many of the substrates in the cell (pyruvate, amino acids, fatty acids), generating reduced nicotinamide adenine dinucleotide (NADH) and reduced flavin adenine dinucleotide (FADHz) for use by the electron transport chain and energy generation.
  • A double-stranded circular DNA genome encodes a few of the mitochondrial proteins. Mitochondrial DNA is always inherited from the mother, resulting in the maternal transmission of diseases of energy metabolism.
  • RNA,proteins, and ribosomes-although there is some protein synthesis, most mitochondrial proteins are synthesized in the cytoplasm and are transferred into the mitochondria.
  • Intramitochondrial granules-contain calcium and magnesium. Their  function is not known, but it is believed that they may represent a storage site for calcium.



Cytoskeleton

The cytoskeleton provides a supportive network of tubules and filaments in the cytoplasm of eukaryotic cells. It is composed of microtubules, intermediate filaments, and microfilaments.

Microtubules


  • Microtubules are polymers of tubulin that undergo rapid assembly and disassembly. They are found in the cytoplasmic matrix of all eukaryotic cells.
  • Tubulin
  • The major component of microtubules is tubulin, a protein dimer composed of two different polypeptides, a-tubulin and l3-tubulin.
  • Polymerization of tubulin to form microtubules is accomplished by microtubule organizing centers and two types of accessory proteins, tau proteins and microtubule-associated proteins. Microtubules grow from the organizing centers. Calcium ions can block or reverse polymerization.
  • Microtubules playa role in:
  • Chromosomal movement during meiosis and mitosis. Microtubule assembly is an
  • important event in spindle formation.
  • Intracellular vesicle and organelle transport. Two specific microtubule-dependent ATPases, kinesin and dynein, are involved in generating the force that drives transport, with the microtubular structure playing a more passive role in intracellular transport.
  • Ciliary and flagellar movement.



Intermediate filaments


  • Intermediate filaments are intermediate in thickness (10-nm diameter) between microtubules and micro filaments. They function primarily in structural roles and contain several types of tissue- specific proteins:
  • Cytokeratins-found in epithelial tissue .
  • Desmin-found in smooth muscle; Z disks of skeletal and cardiac muscle
  • Vimentin-found in cells of mesenchymal origin (endothelial cells, fibroblasts, chondroblasts, vascular smooth muscle) .
  • NeurofIlaments-found in neurons
  • Glial fibrillary acidic protein (GFA)-found in astrocytes


Microfilaments


  • Microfilaments have a diameter of 6 nm and are composed of actin. Each actin filament (F-actin) consists of two strands of actin twisted into a helical pattern with 13.5 molecules of globular actin (G-actin) per turn of the helix.
  • Two types of movement are associated with microfilaments:
  • Local movement takes advantage of the polymerization and depolymerization properties of microfilaments.
  • Sliding filament movement is generated by the interaction of actin filaments with myosin filaments.



Clinical correlates

Chediak-Higashi syndrome


  • Chediak-Higashi syndrome is characterized by defect in microtubule polymerization.
  • This leads to defects in cytoplasmic granules including:
  • Delayed fusion of phagosomes with Iysosomes in leukocyte,thus preventing phagocytosis of bacteria.
  • Increased fusion of melanosomes in melanocytes, leading to albinism.
  • Granular defects in natural killer cells and platelets.


Actin-binding drugs


  • Actin-binding drugs(e.g. cytochalasin B) can interfere with the polymerization-depolymerization cycle of microfilaments. Process such as endocytosis, pagocytosis, cytokinesis, cytoplasmic and amoeboid movements are all inhibited by cytochalasin B.



CELL SURFACE

Basement Membrane


  • The basement membrane is a sheet like structure that underlies virtually all epithelia. It consists of the following:
  • Basal lamina-composed of type IV collagen, glycoproteins (e.g.,laminin), and proteoglycans (e.g., heparan sulfate).
  • Reticular lamina-composed of delicate reticular fibers.


Lateral Surface

Tight junction(zonula occludens)


  • The tight junction is formed by the fusion of opposed cell membranes. These ridges of fusion present as "sealing strands" seen in freeze-fracture replicas. It extends completely around the apical cell borders to seal the underlying intercellular clefts from contact with the outside environment. It constitutes the anatomic component of many barriers in the body.


Zonula adherens


  • A zonula adherens (adherent junction) often lies basal to the zonula occludens.
  • It is a band like junction that serves in the attachment of adjacent epithelial cells.


Desmosome


  • The desmosome (macula adherens) is formed by the juxtaposition of two disk-shaped plaques
  • contained within the cytoplasm of each adjacent cell .
  • Intermediate filaments (tonofilaments) radiate away from the plaques . These intermediate filaments are anchored by desmoplakins (plaques)that also bind to trans membrane linker proteins, linking adjacent cells.
  • Desmosomes are most common in lining membranes, are subject to wear and tear, and are considered spot welds that hold cells together.



Gap junction


  • The gap junction is an area of communication between adjacent cells that allows the passage of very small particles and ions across a small intercellular gap within the junction.
  • The gap junction consists of a hexagonal lattice of tubular protein subunits called connexons, which form hydrophilic channels connecting the cytoplasm of adjacent cells.
  • This permits the direct passage of ions and small molecules between cells to conduct electrical impulses.


Apical (Free) Surface

Microvilli


  • Microvilli are apical cell surface evaginations of cell membranes that function to increase the cell surface area available for absorption. A thick glycocalyx coat covers them. The core of each microvillus contains actin microfilaments. It is anchored in the apical cell cytoplasm to the terminal web, which itself is anchored to the zonula adherens of the cell membrane.


Cilia


  • Cilia are apical cell surface projections of cell membrane that contain microtubules. They are inserted on centriole-like basal bodies present below the membrane surface at the apical pole.
  • Cilia contain two central microtubules surrounded by a circle of nine peripheral microtubule doublets. The peripheral doublets are fused so that they share a common tubule wall and form two subtubules, A and B. Adjacent doublets are connected to one another by nexin links.


Movement of Cilia


  • A pair of dynein arms is attached to each A subtubule. The arms bind to ATP and rearrange themselves so that a binding site for the B subtubule in the tip of the arm is exposed. The B tubule interacts with the binding site, causing the arm to snap back and movement to occur. Each cycle of a single dynein arm slides adjacent doublets 10nm past each other.
  • Cilia move back and forth to propel fluid and particles in one direction. They are important in clearing mucus from the respiratory tract.



Clinical correlates:


  • Stereocilia are elongated microvilli found at the apices of cells lining the epididymis, ductus deferens, and haircells of the inner ear, where they play a role in auditory sensation.
  • Flagella are longer than cilia but have the same microstructure, a prominent example is in the sperm, where the single flagellum provides motility.


Kartagener Syndrome


  • Absent or aberrant dynein arms are found in the cilia and flagella of individuals suffering from Kartagener syndrome (a subset of immotile cilia syndrome).
  • Such individuals often have chronic sinusitis and bronchiectasis as well as infertility and, in some cases, situsinversus.
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Thursday, 31 August 2017

8 WAYS TO IMPROVE SLEEP DURING PREGNANCY

 8 WAYS TO IMPROVE SLEEP DURING PREGNANCY

Newborns have a certain reputation for keeping people up at odd hours with late-night feedings — but the sleepless nights can begin long before your baby arrives.
Figuring out how to get better sleep during pregnancy is not just important for your energy and mood. Pregnant women who get less sleep are more likely to have complications.

How stage of pregnancy affects sleep needs

Depending on the stage of your pregnancy, there are different sleep challenges to overcome.
In the first trimester, women tend to crave a significant amount of sleep. Don’t be surprised if you need to go to bed earlier, take more naps and feel sleepier overall. At this stage, the best thing you can do is to give into this urge, and get the rest your body needs.
In the second trimester, the need for sleep mostly returns to the way it was before you got pregnant.
But the pendulum generally swings again in the third trimester, when women tend to lose sleep.
Discomfort can come from:
  • Back pain
  • Baby kicks
  • Leg cramps
  • More frequent urination urges
  • Substantial weight gain
  • Congestion associated with late-term pregnancy


8 tips to help you get better sleep

Although it’s impossible for women to avoid many of the things that limit sleep during pregnancy, there are ways to get more (and better) rest:
  1. Develop a bedtime routine. It contributes to relaxation.
  2. Avoid electronics for at least an hour before bedtime. If that’s not possible, turn down the screen’s brightness.
  3. Limit caffeine in your diet.
  4. Relieve stress with yoga, mindfulness meditation or massage therapy.
  5. Don’t sleep on your back. It decreases the baby’s oxygen supply and puts pressure on your back.
  6. Sleep on your side. Use pillows to support your abdomen and hips.
  7. Limit breathing problems by elevating your head when you sleep.
  8. Stay well hydrated to help reduce leg cramping.


Poor sleep opens door for ill health

Sleep problems during pregnancy are not inevitable. They can, and should be addressed.
Pregnant women who don’t sleep well are more likely to have:
  • High blood pressure (and related cardiac problems)
  • Poor sugar control (gestational diabetes)
  • Anxiety and depression
  • Postpartum depression (some research shows a link to this condition)
There are also some conditions that appear for the first time or worsen when you’re pregnant.
These conditions can certainly rear their ugly heads in pregnancy and progress at a faster rate. Someone might not have these conditions before pregnancy, and they might develop during any trimester.



Women with pregnancy-related sleep apnea also tend to have:
  • Gestational diabetes
  • Pre-eclampsia (pregnancy-induced hypertension)
  • Smaller babies
Talk to your doctor if you continue to struggle to get enough sleep. He or she can help pinpoint the cause and offer more tips to overcome it.

Monday, 4 April 2016

Boils after shaving??? Be careful to avoid Folliculitis.

Folliculitis is a common skin condition in which hair follicles become inflamed. It's usually caused by a bacterial or fungal infection. At first it may look like small red bumps or white-headed pimples around hair follicles — the tiny pockets from which each hair grows. The infection can spread and turn into nonhealing, crusty sores.
The condition isn't life-threatening, but it can be itchy, sore and embarrassing. Severe infections can cause permanent hair loss and scarring.
If you have a mild case, it'll likely clear in a few days with basic self-care measures. For more serious or recurring folliculitis, you may need to see a doctor.
Certain types of folliculitis are known as hot tub rash, razor bumps and barber's itch.


Image result for folliculitis


Symptoms


Folliculitis signs and symptoms include:
  • Clusters of small red bumps or white-headed pimples that develop around hair follicles
  • Pus-filled blisters that break open and crust over
  • Red and inflamed skin
  • Itchy or burning skin
  • Tenderness or pain
  • A large swollen bump or mass

Types of superficial folliculitis


Superficial forms of folliculitis include:
  • Bacterial folliculitis. This common type is marked by itchy, white, pus-filled bumps. When bacterial folliculitis affects a man's beard area, it's called barber's itch. It occurs when hair follicles become infected with bacteria, usually Staphylococcus aureus (staph). Staph bacteria live on the skin all the time. But they generally cause problems only when they enter your body through a cut or other wound.
  • Hot tub folliculitis (pseudomonas folliculitis). This type is caused by pseudomonas bacteria. You may be exposed to these bacteria in many places, including hot tubs and heated pools in which the chlorine and pH levels aren't well-regulated. You may develop a rash of red, round, itchy bumps one to four days after exposure. These may later develop into small pus-filled blisters (pustules).
    The rash is likely to be worse in areas where your swimsuit held contaminated water against the skin or where skin — such as the back of the thighs — came in direct contact with a contaminated surface.
  • Barber's itch (pseudofolliculitis barbae). This is an inflammation caused by ingrowing hairs. It mainly affects black men who shave and is most noticeable on the face and neck. People who get bikini waxes may develop barber's itch in the groin area. This condition may leave dark raised scars (keloids).
  • Pityrosporum (pit-ih-ROS-puh-rum) folliculitis. This type is especially common in teens and adult men. It's caused by a yeast infection and produces chronic, red, itchy pustules on the back and chest and sometimes on the neck, shoulders, upper arms and face. 

 

Types of deep folliculitis

 

Deep folliculitis, where the whole hair follicle is involved, comes in various forms:
  • Sycosis barbae. This type affects men who have begun to shave. At first, small pustules appear on the upper lip, chin and jaw. They become more prevalent over days and weeks as shaving continues. Severe sycosis barbae may cause scarring.
  • Gram-negative folliculitis. This type sometimes develops if you're receiving long-term antibiotic therapy for acne. Antibiotics alter the normal balance of bacteria in the nose. This leads to an overgrowth of harmful organisms called gram-negative bacteria. In most people, this doesn't cause problems, and the bacteria in the nose return to normal once antibiotics are stopped. In a few people, the gram-negative bacteria spread to the skin around the nose and mouth. This can cause new, severe acne.
  • Boils (furuncles) and carbuncles. These occur when hair follicles become deeply infected with staph bacteria. A boil usually appears suddenly as a painful pink or red bump. The surrounding skin also may be red and swollen. The bump then fills with pus and grows larger and more painful before it finally ruptures and drains. Small boils usually heal without scarring. A large boil may leave a scar.
    A carbuncle is a cluster of boils. It usually appears on the back of the neck, shoulders, back or thighs. A carbuncle causes a deeper and more severe infection than does a single boil. As a result, it develops and heals more slowly and is likely to leave a scar.
  • Eosinophilic (e-o-sin-o-FILL-ik) folliculitis. This type mainly affects people with HIV/AIDS. Symptoms include intense itching and recurring patches of inflamed, pus-filled sores on the scalp, face, neck and upper chest. The sores usually spread and often leave areas of darker than normal skin (hyperpigmentation) when they heal. The exact cause of eosinophilic folliculitis isn't known. But it may involve the same yeast-like fungus responsible for pityrosporum folliculitis.

Causes


Folliculitis is caused by an infection of hair follicles, usually from the bacteria Staphylococcus aureus. May also be caused by viruses, fungi and even an inflammation from ingrown hairs.
The condition is classified as either superficial or deep, based on how much of the hair follicle it involves. Deep folliculitis is usually more severe.
Follicles are densest on your scalp, and they occur everywhere on your body except your palms, soles, lips and mucous membranes. Damaged follicles are at risk of infection.
The most common causes of follicle damage are:
  • Friction from shaving or tight clothing
  • Heat and sweat, such as that caused by wearing rubber gloves or waders
  • Certain skin conditions, such as dermatitis and acne
  • Injuries to your skin, such as from scrapes or surgical wounds
  • Coverings on your skin, such as plastic dressings or adhesive tape


Risk factors


Anyone can develop folliculitis. But certain factors make you more susceptible to the condition, including:
  • Having a medical condition that reduces your resistance to infection, such as diabetes, chronic leukemia and HIV/AIDS
  • Having acne or dermatitis
  • Past damage to your skin, as from injury or surgery
  • Taking some medications, such as steroid creams or long-term antibiotic therapy for acne
  • Being overweight
  • Regularly wearing clothing that traps heat and sweat, such as rubber gloves or high boots
  • Soaking in a hot tub that's not maintained well
  • Shaving


Complications


Possible complications of folliculitis include:
  • Recurrent or spreading infection
  • Large, itchy patches of infected skin (plaques)
  • Boils under the skin (furunculosis)
  • Permanent skin damage, such as scarring or dark spots
  • Destruction of hair follicles and permanent hair loss

Prevention


You can try to prevent folliculitis from coming back with these tips:
  • Avoid tight clothes. It helps to reduce friction between your skin and clothing.
  • Dry out your rubber gloves between uses. If you wear rubber gloves regularly, after each use turn them inside out, rinse with soap and water, and dry thoroughly.
  • Avoid shaving, if possible. For men with barber's itch, growing a beard may be a good option if you don't need a clean-shaven face.
  • Shave with care. Use an electric razor or a clean, sharp blade every time you shave. Adopt habits such as:
    • Washing your skin with warm water and a mild facial cleanser before shaving
    • Using a wash cloth or cleansing pad in a gentle circular motion
    • Applying lubricating shaving cream or gel for five to 10 minutes before shaving to soften the hair
    • Applying moisturizing lotion after you shave
    Generally, men with barber's itch have been advised to shave in the direction of hair growth. But a study found that men who shaved against the grain saw their rash improve. Experiment to see what works for you. You may even want to consider hair-removing products (depilatories) or other methods of hair removal.
  • Use only clean hot tubs and heated pools. And if you own a hot tub or a heated pool, clean it regularly and add chlorine as recommended.
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 Gynaecology-Centre-Nairobi

Friday, 1 April 2016

Galactorrhea

 

Galactorrhea (guh-lack-toe-REE-uh) is a milky nipple discharge unrelated to the normal milk production of breast-feeding. Galactorrhea itself isn't a disease, but it could be a sign of an underlying problem. It usually occurs in women, even those who have never had children or after menopause. But galactorrhea can happen in men and even in infants.
Excessive breast stimulation, medication side effects or disorders of the pituitary gland all may contribute to galactorrhea. Often, galactorrhea results from increased levels of prolactin, the hormone that stimulates milk production.
Sometimes, the cause of galactorrhea can't be determined. The condition may resolve on its own.

 

Symptoms

Signs and symptoms associated with galactorrhea include:
  • Persistent or intermittent milky nipple discharge
  • Nipple discharge involving multiple milk ducts
  • Spontaneously leaked or manually expressed nipple discharge
  • One or both breasts affected
  • Absent or irregular menstrual periods
  • Headaches or vision problems




Causes

Image result for hypothalamus and pituitary

Galactorrhea often results from too much prolactin — the hormone responsible for milk production (lactation) when you have a baby. Prolactin is produced by your pituitary gland, a marble-sized gland at the base of your brain that secretes and regulates several hormones.
Possible causes of galactorrhea include:
  • Medications, such as certain sedatives, antidepressants, antipsychotics and high blood pressure drugs
  • Cocaine, marijuana or opioid use
  • Herbal supplements, such as fennel, anise or fenugreek seed
  • Birth control pills
  • Noncancerous pituitary tumor (prolactinoma) or other disorder of the pituitary gland
  • Underactive thyroid (hypothyroidism)
  • Chronic kidney disease
  • Excessive breast stimulation, which may be associated with sexual activity, frequent breast self-exams with nipple manipulation or prolonged clothing friction
  • Nerve damage to the chest wall from chest surgery, burns or other chest injuries
  • Spinal cord surgery, injury or tumors

 

Idiopathic galactorrhea

Sometimes doctors can't find a cause for galactorrhea. This is called idiopathic galactorrhea, and it may just mean that your breast tissue is particularly sensitive to the milk-producing hormone prolactin in your blood. If you have increased sensitivity to prolactin, even normal prolactin levels can lead to galactorrhea.

 

Galactorrhea in men

In males, galactorrhea may be associated with testosterone deficiency (male hypogonadism) and usually occurs with breast enlargement or tenderness (gynecomastia). Erectile dysfunction and a lack of sexual desire also are associated with testosterone deficiency.

 

Galactorrhea in newborns

Galactorrhea sometimes occurs in newborns. High maternal estrogen levels cross the placenta into the baby's blood. This can cause enlargement of the baby's breast tissue, which may be associated with a milky nipple discharge



When to see a doctor

If you have a persistent, spontaneous milky nipple discharge from one or both of your breasts and you're not pregnant or breast-feeding, make an appointment to see your doctor.
If breast stimulation — such as excessive nipple manipulation during sexual activity — triggers nipple discharge from multiple ducts, you have little cause for worry. The discharge probably doesn't signal anything abnormal, including breast cancer, but you should still see a doctor for evaluation.
Nonmilky nipple discharge — particularly bloody, yellow or clear spontaneous discharge that comes from one duct or is associated with a lump you can feel — requires prompt medical attention, as it may be a sign of an underlying breast cancer.Gynaecology-Centre-Nairobi