Source Emedicine-""Hydralazine (Apresoline) -- First-line therapy against preeclamptic hypertension.
Labetalol (Normodyne) -- Second-line therapy that produces vasodilatation and decreases in systemic vascular resistance.
Hydralazine is the DOC for BP control in eclampsia.""
A 22-year-old primigravida is hospitalized at 34 weeks gestation because of blurred vision, headache, and pain in the right upper quadrant of the abdomen. Her temperature is 36.7 C ([snip] F), blood pressure is 220/110 mmHg, pulse is 80/min, and respirations are 20/min. The fundoscopic exam is normal. On examination, you note swelling of both her hands and her face, bilateral exaggeration of deep tendon reflexes with clonus, and a positive Babinski. The pelvic exam shows 50% effacement, and 3 cm dilation of the cervix. While getting IV access, the patient started to have generalized tonic-clonic seizures. An airway is secured, and breathing is present. Urinalysis revealed proteinuria of 3+ .
Item 1 of 4
Which of the following is the most effective strategy to decrease this patient"s risk for developing further complications?
A) Check vital signs every four hours
B) Start magnesium sulfate infusion
C) Speed vaginal delivery
D) Start parenteral clonidine
E) Start phenytoin infusion
The correct answer is: C
41% of the people have answered this question correctly
Explanation:
This patient was admitted to the hospital because she has a severe preeclampsia, which was later complicated with eclampsia. Patients with severe preeclampsia are at greater risk of developing eclampsia. The first priority in patients with eclampsia or postictal coma is respiratory and cardiovascular resuscitation. Anticonvulsant medications can be administered after placing two large-bore needles in the patient. The most effective agent used in these cases is magnesium sulfate; however, the most effective treatment to prevent further complications is to accelerate delivery (Choice C). Eclampsia can cause several other complications besides seizures, such as disseminated intravascular coagulopathy, acute renal failure, hepatocellular injury, liver rupture, intracerebral hemorrhage, etc. Magnesium sulfate prevents seizures, but it will not stop the pathologic process.
Again, magnesium sulfate will be beneficial, but not as effective as pregnancy termination (Choice B). This would have been a correct choice if the question was asked about the next step in the management of this patient, because the hemodynamic stability and seizure control are important before attempting delivery.
Clonidine is not indicated in this setting (Choice D). Either hydralazine or labetalol are the antihypertensive drugs of choice.
Phenytoin or diazepam is not as effective as magnesium sulfate in controlling seizures; but, again, seizures are not the only complication of eclampsia. Speeding up the delivery is the most important (Choice E).
Frequent monitoring of vital signs is part of the management, but it will not prevent the patient from developing further complications (Choice A).
Educational Objective:
Eclampsia is a serious complication of pregnancy. If the patient is in the third trimester, especially in the last six weeks, termination of pregnancy is advised in order to stop the pathologic process. There is no pharmacologic therapy more effective than this intervention.
A 22-year-old primigravida is hospitalized at 34 weeks gestation because of blurred vision, headache, and pain in the right upper quadrant of the abdomen. Her temperature is 36.7 C ([snip] F), blood pressure is 220/110 mmHg, pulse is 80/min, and respirations are 20/min. The fundoscopic exam is normal. On examination, you note swelling of both her hands and her face, bilateral exaggeration of deep tendon reflexes with clonus, and a positive Babinski. The pelvic exam shows 50% effacement, and 3 cm dilation of the cervix. While getting IV access, the patient started to have generalized tonic-clonic seizures. An airway is secured, and breathing is present. Urinalysis revealed proteinuria of 3+ .
Item 1 of 4
Which of the following is the most effective strategy to decrease this patient"s risk for developing further complications?
A) Check vital signs every four hours
B) Start magnesium sulfate infusion
C) Speed vaginal delivery
D) Start parenteral clonidine
E) Start phenytoin infusion
The correct answer is: C
41% of the people have answered this question correctly
Explanation:
This patient was admitted to the hospital because she has a severe preeclampsia, which was later complicated with eclampsia. Patients with severe preeclampsia are at greater risk of developing eclampsia. The first priority in patients with eclampsia or postictal coma is respiratory and cardiovascular resuscitation. Anticonvulsant medications can be administered after placing two large-bore needles in the patient. The most effective agent used in these cases is magnesium sulfate; however, the most effective treatment to prevent further complications is to accelerate delivery (Choice C). Eclampsia can cause several other complications besides seizures, such as disseminated intravascular coagulopathy, acute renal failure, hepatocellular injury, liver rupture, intracerebral hemorrhage, etc. Magnesium sulfate prevents seizures, but it will not stop the pathologic process.
Again, magnesium sulfate will be beneficial, but not as effective as pregnancy termination (Choice B). This would have been a correct choice if the question was asked about the next step in the management of this patient, because the hemodynamic stability and seizure control are important before attempting delivery.
Clonidine is not indicated in this setting (Choice D). Either hydralazine or labetalol are the antihypertensive drugs of choice.
Phenytoin or diazepam is not as effective as magnesium sulfate in controlling seizures; but, again, seizures are not the only complication of eclampsia. Speeding up the delivery is the most important (Choice E).
Frequent monitoring of vital signs is part of the management, but it will not prevent the patient from developing further complications (Choice A).
Educational Objective:
Eclampsia is a serious complication of pregnancy. If the patient is in the third trimester, especially in the last six weeks, termination of pregnancy is advised in order to stop the pathologic process. There is no pharmacologic therapy more effective than this intervention.
5. (QId - 221)
Item 2 of 4
Which of the following is the most effective agent to treat hypertension in this patient?
A) Methyldopa
B) Labetalol
C) Enalapril
D) Amlodipine
E) Atenolol
The correct answer is: B
52% of the people have answered this question correctly
Explanation:
In pregnant patients with a hypertensive crisis, either hydralazine or labetalol are the antihypertensive drugs of choice.
ACE inhibitors are contraindicated in pregnancy (Choice C).
(Choice A) Methyldopa is the preferred agent for oral therapy in mild to moderate hypertension. Calcium channel blockers are added to methyldopa as second line agents (Choice D).
(Choice E) Atenolol is an oral agent (in USA) and is not indicated in the acute setting. Although beta-blockers are considered to be safe, there are some reports of impaired fetal growth, especially with atenolol if used in the early part of a pregnancy.
Educational Objective:
Either hydralazine or labetalol are the antihypertensive drugs of choice in the acute setting in a pregnancy. Methyldopa is preferred for oral therapy in mild to moderate hypertension in a pregnancy.
6. (QId - 222)
Item 3 of 4
During labor, the patient had another seizure. Which of the following is the most appropriate pharmacotherapy in order to avoid seizure recurrence in these patients?
A) Phenytoin
B) Magnesium sulfate
C) Phenobarbital
D) Diazepam
E) Valproic acid
The correct answer is: B
72% of the people have answered this question correctly
Explanation:
Anti-seizure prophylaxis in a patient with eclampsia has been a topic of prolonged debate. Recently, some studies have confirmed that magnesium sulfate is not only the best anticonvulsant medication for patients with eclampsia, but it is also the more effective agent to prevent further seizures (Choice B).
With diazepam, there is a greater risk of respiratory depression. Magnesium sulfate is proven to be more effective and to have a low neonatal morbidity. Diazepam is more useful in the setting of status epilepticus, or if the patient has contraindications to use magnesium sulfate, such as myasthenia gravis (Choice D).
Phenytoin can be useful, but it is not as effective as magnesium sulfate (Choice A). Phenobarbital is reserved only for those cases in which seizures persist, despite the use of magnesium sulfate, diazepam, or phenytoin (Choice C). Valproic acid is not part of the therapy of eclampsia (Choice E).
Educational Objective:
The best medication to prevent further seizures in a patient with eclampsia is magnesium sulfate. Diazepam or phenytoin can be added to the therapy if seizures persist, even though the use of diazepam is limited because of depressant effects on the fetus.
7. (QId - 223)
Item 4 of 4
Presence of which of the following is considered an extremely ominous sign/feature of this condition?
End of Set
A) Increased PGI 2 and Thromboxane A 2 ratio
B) Retinal hemorrhages
C) Glomerular capillary endotheliosis
D) Microangiopathic hemolytic anemia
E) Subcapsular hematoma of the liver
The correct answer is: B
40% of the people have answered this question correctly
Explanation:
This patient has preeclampsia complicated by eclampsia. Retinal hemorrhage is considered to be an extremely ominous sign, because it reflects the vascular damage that has occurred in other organs. Retinal vasospasm can also be seen in preeclampsia and can be visualized on ophthalmoscopic examination.
(Choice A) Opposite to normal pregnancy, the PGI 2 to Thromboxane A 2 ratio decreases and does not increase. This change results in an increase in peripheral resistance and, thus, clinical symptoms and complications of preeclampsia and eclampsia. A deficiency in nitric oxide, as well as an increase in Endothelin-I, have also been incriminated -- the former being a vasodilator and the latter a potent vasoconstrictor.
(Choice C) Glomerular capillary endotheliosis is the typical glomerular lesion of preeclampsia/eclampsia. It involves a marked swelling of the glomerular capillary endothelium and deposits of fibrinoid material in and beneath the endothelial cells. The glomerular diameter is increased on light microscopy, with endothelial and mesangial cell swelling.
(Choice D) Microangiopathic hemolytic anemia can occur in preeclampsia and eclampsia, but it is not considered an ominous sign. It results from the injury of RBC by the damaged endothelium that is usually associated with the condition.
(Choice E) Vasoconstriction of the hepatic vasculature can result in necrosis and hemorrhage of the periportal spaces and, ultimately, subcapsular hematoma.
Educational Objective:
Retinal hemorrhage is considered to be an extremely ominous sign of preeclampsia/eclampsia.
most common tumor during pre-puberty
a)endodermal sinus tumor
b)teratoma
c)embryonalcarcinoma
d)seminoma
ans:teratoma
ref
p442
Editors: Halperin, Edward C.; Constine, Louis S.; Tarbell, Nancy J.; Kun, Larry E.
Title: Pediatric Radiation Oncology, 4th Edition
Teratomas (from Greek teratos, “monster,” and onkoma, “swelling”) are the most common pediatric GCTs.
yolksac [endodermal sinus tumor]is also germ cell tumor
Teratocarcinoma is an old name for a germ cell tumor that is a mixture of teratoma and embryonal carcinoma. In more modern usage, this kind of mixed germ cell tumor may be known as a teratoma with elements of embryonal carcinoma
The most common types of prepubertal testis. tumors are yolk sac tumors
yolksac [endodermal sinus tumor]is also germ cell tumor
Teratocarcinoma is an old name for a germ cell tumor that is a mixture of teratoma and embryonal carcinoma. In more modern usage, this kind of mixed germ cell tumor may be known as a teratoma with elements of embryonal carcinoma
regarding NHLstomach one option was surgery n chemotherapy remain mainstay of treatment
X ray skull in increased i.c.t. had ' sutural diastasis' as one of da options.........hope dis helps!
drfuntoosh wrote:
dragonlives4ever wrote:
dev2020 wrote:
sorry dear,i haven't found the answer yet...will post once i find it
dear,
i dont think ans will change,u will be most welcome with new ans but proper explan and any ref net or book
btw whatz da answer as per u dragon??? hav u given it in earlier discussion????refering 2 hunter,hurler, gaucher q
YES I HAVE GIVEN ANS AS HUNTERS DS AT BOTTOM OF POST,BUT UNSURE ABT IT,NEED BETTER
BUT HUNTER'S IS A X-LINKED RECESSIVE DISEASE,SO MALES WILL BE EFFECTED.
yaa ,u r right,i have not attempted the q uestion,but what do they mean by its mostly seen in females?
other diseases are autosomal.
the question was on NHL and not on HODGKIN as in kavish book
all net citations indicating Chlorpropamide to decrease free water clearance in diabetes insipidus by sensitising tubules to action of ADH.
Endocrine Reactions: On rare occasions, Chlorpropamide has caused a reaction identical to the syndrome of inappropriate antidiuretic hormone (ADH) secretion. The features of this syndrome result from excessive water retention and include hyponatremia, low serum osmolality, and high urine osmolality. This reaction has also been reported for other sulfonylureas.
good man gilman
11th edn
Carbamazepine and chlorpropamide also enhance the antidiuretic effects of vasopressin by unknown mechanisms. In rare instances, chlorpropamide can induce water intoxication.
Chlorpropamide, an oral sulfonylurea, potentiates the action of small or residual amounts of circulating vasopressin and will reduce urine volume in more than half of all patients with central DI. A dose of 125 to 500 mg daily is particularly effective in patients with partial central DI. If polyuria is not controlled satisfactorily with chlorpropamide alone, addition of a thiazide diuretic (see Chapter 28) to the regimen usually results in an adequate reduction in the volume of urine.
The major V2-receptor-mediated adverse effect is water intoxication, which can occur with desmopressin or vasopressin. In this regard, many drugs, including carbamazepine, chlorpropamide, morphine, tricyclic antidepressants, and NSAIDs, can potentiate the antidiuretic effects of these peptides
This is what KDT 5th Pg-526 has to say. Frusemide abolishes the cortico medullary osmotic gradient & blocks positive as well as negative free water clearance.
Now the original question was:
Which of the following drugs decreases negative free water clearance:….
If Frusemide blocks both positive &negative free water clearance then it WILL NOT DECREASE the negative free water clearance.
So, a drug having ADH like action can only DECREASE the negative free water clearance.
This is my view point Kavish. I know I may be wrong as well.
f the free water clearance has a positive value, the urine is hypotonic, and if negative, the urine is hypertonic.
DRUGS ASSOCIATED WITH HYPONATREMIA
Antidiuretic hormone analogues
Deamino-D-arginine vasopressin (DDAVP)
Oxytocin
Drugs that enhance release of antidiuretic hormone
Chlorpropamide
Clofibrate
Carbamazepine-oxycarbazepine
Vincristine
Nicotine
Narcotics
Antipsychotics
Antidepressants
Ifosfamide
Drugs that potentiate renal action of antidiuretic hormone
Chlorpropamide
Cyclophosphamide
Nonsteroidal anti-inflammatory drugs
Acetaminophen
Drugs that cause hyponatremia by unknown mechanisms
Haloperidol
Fluphenazine
Amitriptyline
Thioradazine
Fluoxetine
Excessive decrease in free water clearance induced by furosemide and ethacrynic acid in nephrogenic diabetes insipidus associated with renal tubular acidosis.
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