Please enable JavaScript.

Coggle requires JavaScript to display documents.

PBL (Group 3), Infant born with cleft lip, Low Birth Weight,…

- - - - Prednisone + azathioprine
        
        mild to severe drug interaction in patient as the adverse effects will be increased
        
        can increase the immunosuppressive effects in patient and then results in high chances of infections
        sign and symptom
        
        high chances to get bacterial infections
        
        less antibodies can fight against the bacteria or virus
      - Prednisone + Piperacillin
        
        PHARMACOKINETIC INTERACTION (Excretion reaction)
        
        Prednisone is a corticosteroid that is used to treat immune-mediated reactions.
        
        Piperacillin is a penicillin beta-lactam antibiotic.
        
        The piperacillin will interact with prednisone to decrease the excretion rate of the prednisone, then leading to an increase in the concentration of prednisone in the serum level.
        
        The piperacillin has more potential in competing for renal excretion than prednisone, so the piperacillin will be more prone to be excreted when compared to prednisone.
        
        Then, the renal elimination of prednisone will be delayed and leading to the increase in serum concentration of prednisone.
        
        Acne, blurred vision, and changes in behavior or mood
        
        High serum levels of prednisone will also cause irregularities in potassium, calcium, and phosphate levels and leading to high blood pressure.
        
        May cause the patient to have cardiovascular problems
        
        Increase the risk of GI perforation and increase in the risk of getting an infection
      - Azathioprine + Piperacillin
        
        PHARMACOKINETIC INTERACTION (Excretion reaction)
        
        Azathioprine is an immunosuppressant that is used to decrease the actions of the body's immune system.
        
        Piperacillin is a penicillin beta-lactam antibiotic.
        
        Piperacillin will interact with azathioprine to decrease the excretion rate of the azathioprine, then leading to an increase in the concentration of azathioprine in the serum level.
        
        Similar mechanism of action like Interaction between prednisone and piperacillin
        
        The renal elimination of azathioprine will be delayed and leading to the increase in serum concentration of azathioprine.
        
        Stomach problems which include nausea, diarrhoea, and vomiting.
        
        Lead to low white blood cells counts and cause the patient more prone to get infections due to the weakened immune system.
  - - - Interaction between prednisone and lobar pneumonia
        
        Prednisone is a corticosteroid that is used to suppress the activity of the immune system to reduce the production of antibodies to minimize the effect of myasthenia gravis, MG in the patient.
        
        It will cause the patient more prone to get infections and worsen the infection’s conditions.
        
        Prednisone will use doubled the rate of serious bacterial infections such as pneumonia.
        
        The length of treatment and dose of prednisone should be adjusted accurately based on the patient’s conditions.
      - Interaction between azathioprine and lobar pneumonia
        
        Azathioprine is an immunosuppressant that is also used to suppress the immune system to manage the condition of the myasthenia gravis, MG in the patient.
        
        It will reduce the body’s resistance of patient against the infection, then making the patient more prone to get a severe infection and worsen the condition of the infection.
        
        The drug dose and duration of the treatment plan should be controlled and monitored accurately to minimize the risk of getting an infection or causing the severe condition of infection.
      - Interaction between pyridostigmine bromide and secondary generalized seizures
        
        Pyridostigmine bromide is an anticholinesterase that will improve the muscle strength of the patient with myasthenia gravis, MG by preventing the breaking down of the acetylcholine in the synaptic cleft.
        
        Pyridostigmine bromide will cause seizures.
        
        Seizure is caused by the higher in concentration of acetylcholine in the brain due to a decrease in the activity of acetylcholinesterase.
        
        The length of treatment and dosage of pyridostigmine bromide should be adjusted and monitored critically and accurately.
      - Interaction between the combination of piperacillin and tazobactam and secondary generalized seizures
        
        Piperacillin is a beta-lactam antibiotic (Penicillin class) that is used for the treatment of bacterial infections such as pneumonia.
        
        The tazobactam will act as a beta-lactamase inhibitor to prevent the degradation of the piperacillin by the enzyme beta-lactamase of bacteria.
        
        It will be the factor that will cause neurotoxicity.
        
        Seizures are believed that it is most probably induced by beta-lactam drugs such as piperacillin based on a research article.
  - - - Pyridostigmine bromide (anticholinesterase)
        
        Consumptions of alcohol should be avoided due to it can increase some side effects of pyridostigmine bromide such as stomach pain, nausea and vomiting
        
        Vitamins as well as herbal should be avoided as these can cause interactions with drug
        
        Spicy food should be avoided as drug side effects might increase
      - Prednisone (corticosteroids)
        
        can cause stomach bleeding if taken alcohol due to it can increase the possibility of stomach bleeding as well as indigestion
        
        chance to get kidney and liver damage so alcoholic drinks should be avoided
      - Azathioprine (immunosuppressants)
        
        avoid using alcohol or tobacco due to alcohol can cause liver toxicity
        
        raw or half cooked food such as sashimi or half-cooked egg should be avoided as it can cause food poisoning
        
        Supplement such as Echinacea also need to be avoided as it will decrease the action of azathioprine
      - Piperacillin (antibiotics)
        
        grapefruit should be avoided due to the sour citrus product might disrupt the absorption
        
        furanocoumarins in grapefruit can disrupt the liver as well as intestine to breakdown medications and excrete toxin. Thus, the body cannot metabolize and also absorb the medication properly and results in medication useless.
        
        alcohol need to be avoided as it can results in unpleasant adverse effects
      - Tazobactam (antibiotics)
        
        -similar with Piperacillin-
- - - - Native American Chief Opechancanough who died in 1664
        
        Excessive fatigue
        
        Astasis
        
        Heavy eyelids
      - English physician, Willis, in 1672
        
        Fatigable weakness
        
        Ocular muscles
        
        Bulbar muscles
      - Wilhelm Erb in 1879
        
        Bilateral ptosis
        
        Termed as "Erb's disease" and later "Erb-Goldflam syndrome"
        
        Diplopia
        
        Facial paresis
        
        Weakness of neck muscles
      - Mary Walker in 1934
        
        Symptoms of MG were somewhat similar to curare poisoning, which prompted the usage of physostigmine to treat MG (cholinesterase inhibitor)
      - Blalock in 1937
        
        suggested patients to undergo thymectomy
      - Nastuk and Simpson in 1960
        
        proposed that MG is associated with autoimmune disease
        
        Prednisone and azathioprine coupled with plasma exchange were recognized as the standard treatment for severe MG in 1970
    - - Anti-AChR Ab activates complement
        
        Damage of the postsynaptic membrane at NM
        
        Anti-AChR Ab crosslink with AChRs
        
        Anti-MuSK Ab do not activate complement and prevent the interaction of MuSK and Lrp4
        
        Reduced AChR clustering on the postsynaptic membrane
        
        Accelerated internalization and degradation rate
        
        Production of membrane attack complex (MAC)
      - People at risk
        
        Being a woman between the ages of 20 to 30
        
        Being a man between the ages of 60 to 70
        
        Having specific genetic markers called HLA-B8 or DR3
        
        Newborn infants with mothers who have abnormal antibodies that have entered the baby’s body via the placenta during pregnancy
      - Risk factors of MG
        
        Predisposing genetic factors
        
        Monozygotic and heterozygous twins are likely to develop MG
        
        HLA genes, PTPN22, CTLA4, IL1B, IL10, TNF, IFNG & CD86
        
        linked to autoimmunity
        
        Genetic variation in the promoter region of CHRNA1
        
        MicroRNAs
        
        Mediate post-transcriptional gene silencing
        
        Dysregulated in various autoimmune disease
        
        Increase in pro-inflammatory cytokines
        
        miR-150-5p and let-7
        
        Sex hormones
        
        Oestrogens can influence anti-inflammatory and pro-inflammatory responses
        
        Oestrogen and testosterone affect the expression of thymic transcription factors
        
        AIRE
        
        Environmental factors
        
        Thymus is sensitive to infections
        
        B-cells infected with Epstein-Barr virus
        
        Lack of studies
        
        West Nile virus and Zika virus
        
        Cancer immunotherapy
        
        Other autoimmune and rheumatic diseases
        
        Programmed cell death and cytotoxic T lymphocyte associated protein 4
        
        Lifestyle factors
        
        Smoking
        
        Obesity
        
        Insufficient diet
        
        Physical activity
    - - A common autoimmune disorder in which the body's immune system attacks the connection between the nerve and muscle in the neuromuscular junction, resulting in muscle weakness.
        
        Heterogenous disease that is treatable
      - Common symptoms:
        
        Ocular weakness
        
        Limb weakness
        
        Bulbar weakness
        
        Respiratory muscle weakness
      - Usually starts from childhood to late adulthood
        
        Peaks in younger adult women and older men
      - Classified as antibody-mediated autoimmune disease
        
        Type II hypersensitivity reaction
        
        IgG antibodies react with intra or extracellular antigens that ultimately leads to end-organ damage
        
        Majority
        
        Autoantibodies against acetylcholine receptors (AChRs)
        
        Minority
        
        Seropositive for antibodies
        
        Low-density lipoprotein receptor-related protein 4 (Lrp4)
        
        Agrin
        
        Muscle-specific kinase (MuSK)
        
        Define disease subgroups and describe phenotypic variants
        
        Striational antibodies
        
        Ryanodine receptor
        
        Alpha subunit of voltage-gated K+ channel (Kv1.4)
        
        Titin
        
        Antibodies act as biomarkers of a disease severity
        
        Late-onset MG
        
        Thymoma
        
        Myositis
        
        Myocarditis
    - - The patient previously diagnosed with myasthenia gravis
      - The patient also undergone thymectomy
        
        Thymectomy is a surgery to remove thymus gland which has been shown to play a crucial role in treating myasthenia gravis
        
        The purpose of a thymectomy is to remove the source disease-causing abnormal antibody production, which from thymus gland. This will result in symptoms relief in patient
        
        Factors that will influence the patient's response toward thymectomy: age, reaction toward previous medical therapy, severity of the thymectomy and length of the patient experienced MG
      - A 38-year-old pregnant woman previously a thymectomized with immune-mediated myasthenia gravis, underwent an elective cesarean operation under spinal anesthesia at 35 + 3 weeks of pregnancy, after having a premature rupture of membranes. The patient exhibited no contractions and no signs of muscle weakness at admission, despite taking pyridostigmine bromide, prednisone, and azathioprine. After that, she gave birth to a healthy boy child. However, she experienced respiratory insufficiency on the second postpartum day. The myasthenic crisis resulted in increasing dyspnoea, which was aggravated by a secondary generalized seizure accompanied by cardiac-circulatory arrest. The patient is stable after CPR and is transported to ICU for treatment. The test results revealed a raised antibody level, increased inflammatory levels, and the presence of lobar pneumonia. The interdisciplinary therapeutic approach included ventilatory assistance via endotracheal intubation, parenteral antibiotics (piperacillin and tazobactam), pyridostigmine, azathioprine, and corticosteroids. By these contemplated measures, a stable state was regained. :
    - - Idiopathic where, in most cases, IgG to AChR is present
      - Negative for anti-AChR antibodies is indicative of seropositive for antibodies against MuSK
      - Human leukocyte antigen (HLA) genotyping
        
        HLA-A1
        
        HLA-A3
        
        HLA-B7
        
        HLA-B8
        
        HLA-DRw3
        
        HLA-DQw2
      - Sensitization to foreign antigens that have cross-reactivity with the nicotinic ACh receptor
      - Several drugs that aggravate symptoms of MG
      - Underlying conditions:
        
        Thymic abnormalities
        
        Extrathymic tumors
        
        Hyperthyroidism
    - - Class IIIa
        
        Limb and axial muscles predominantly affected
      - Class IIIb
        
        Oropharyngeal and respiratory muscles predominantly affected
      - Class III
        
        Moderate muscle weakness
        
        Ocular muscle weakness of any severity
      - Class IV
        
        Severe muscle weakness
        
        Ocular muscle weakness of any severity
      - Class IVa
        
        Limb and axial muscles predominantly affected
      - Class IIb
        
        Oropharyngeal and respiratory muscles predominantly affected
      - Class V
        
        Intubation with or without mechanical ventilation
        
        Use of feeding tube without intubation in patient of class IVb
      - Class II
        
        Mild muscle weakness
        
        Ocular muscle weakness of any severity
      - Class IVb
        
        Oropharyngeal and respiratory muscles predominantly affected
      - Class IIa
        
        Limb and axial muscles predominantly affected
      - Class I
        
        Ocular muscle weakness
        
        Weakness of eye closure
        
        Normal muscle strengths
    - - Double seronegative generalized MG
        
        Negative results for AChR and MuSK antibody testing
        
        Antibodies against unidentified antigens
        
        Similar clinical manifestations to those positive for AChR antibodies
        
        Milder symptoms and occurs at a younger age
      - Lrp4 antibody-associated MG
        
        Effector mechanisms
        
        Lrp4
        
        Post-synaptic receptor of nerve-derived agrin
        
        Agrin binds to Lrp4 to activate MuSK and initiate a cascade of events
        
        Aggregation of AChRs in NM
        
        Half of double seronegative MG cases exhibit Lrp4 antibodies
        
        Against agrin
        
        IgG1/IgG2 subclass
        
        Disrupts activation of MuSK
        
        Reduces clustering of AChRs
        
        1 more item...
        
        Congenital myasthenic syndrome
        
        NM is less stable
        
        1 more item...
        
        Gene mutations in agrin
        
        Signs and symptoms
        
        Predominantly female before age 50
        
        Milder symptoms
        
        Severe symptoms in patients with anti-Lrp4 and anti-agrin antibodies
        
        Ocular muscle weakness
        
        Amyotrophic lateral sclerosis
      - MuSK antibody-associated MG
        
        Effector mechanisms
        
        MuSK
        
        Forms AChR clusters in NM
        
        Membrane protein
        
        Activation of MuSK via phosphorylation
        
        Agrin reacts with Lrp4 to form Lrp4/MuSK complex
        
        Phosphorylated MuSK activates a downstream signalling pathway
        
        Clustering of AChRs
        
        Predominantly female
        
        Pathogenic
        
        IgG4 subclass
        
        Do not fix complement
        
        Weak activators of cell-mediated cytotoxicity
        
        Monovalent
        
        1 more item...
        
        Binds to Ig-like domain of the protein
        
        Prevents phosphorylation
        
        Disrupts Agrin-Lrp4-MuSK-Dok-7 signalling pathway
        
        1 more item...
        
        Reduces amount of AChRs
        
        Signs and symptoms
        
        Cranial and bulbar muscle weakness
        
        Tongue atrophy
        
        Diplopia
        
        Ptosis
        
        Limb weakness
        
        Muscle atrophy
        
        Young adults
      - Pediatric MG
        
        Juvenile MG (JMG)
        
        Mg in patients younger than age 18
        
        More prevalent in asian counterparts
        
        Ocular JMG: pre-pubertal children
        
        Generalized JMG: post-pubertal children
        
        Risk for long-term sequelae
        
        Strabismus
        
        Amblyopia
        
        Generalized JMG is unpredictable and often associated with myasthenic crisis
        
        Undergo periodic spontaneous remissions
        
        Similar pathogenic antibodies
        
        AChR Ab
        
        MuSK
        
        Lrp4
        
        Congenital myasthenic syndrome
        
        Mitochondrial disease
        
        Demyelinating polyneuropathies
        
        Congenital myopathies
        
        Ptosis
        
        Ophthalmoparesis
        
        Neonatal MG
        
        Born to mothers with MG due to passive transfer of maternal antibodies in utero
        
        Hypotonia
        
        Respiratory distress
        
        Poor sucking
        
        Extraocular muscle weakness
        
        Persistent myopathic features
        
        Arthrogryposis multiplex congenital
        
        Respiratory support
        
        Neostigmine
        
        Plasma exchange (severe)
      - MG due to antibodies against AChr
        
        Signs and symptoms
        
        Fatigable muscle weakness
        
        Diplopia
        
        Ptosis
        
        Bulbar muscle weakness
        
        Flaccid dysarthria
        
        Dysphagia
        
        Facial and jaw weakness
        
        Axial weakness
        
        Neck flexion weakness
        
        Dropped head syndrome (DHS)
        
        Limb muscle weakness
        
        Weakness in finger
        
        Foot drop
        
        Respiratory weakness
        
        Spontaneous remission may occur in the course of adult-onset MG
        
        Effector mechanisms
        
        AChR antibodies against the AChR alpha subunits are more pathogenic
        
        Why?
        
        Location of AChR alpha subunit is more exposed to antibodies
        
        Role of AChR alpha subunit in modulating the receptor sensitivity to ACh binding
        
        IgG1 and IgG3 antibodies
        
        Impair receptor
        
        Antibody binds to nAChR and activates the complement system
        
        Membrane attack complex (MAC) forms
        
        5 more items...
      - AChR MG
        
        Ocular MG
        
        Antibodies against AChRs
        
        Extraocular muscles (EOMs) fatigue easily
        
        EOMs have a lower density of AChR
        
        Susceptible to symptoms
        
        Variety of epitope expression in EOMs
        
        High frequency of synaptic firing within fibers
        
        Tonic contractions
        
        Generalized AChR Ab Positive MG (AChR-MG)
        
        Early-onset MG (EOMG)
        
        Before age 50
        
        Predominantly female
        
        Higher incidence of thymic hyperplasia
        
        1 more item...
        
        Late-onset MG (LOMG)
        
        After age 50
        
        Predominantly male after age 60
        
        Thymic hyperplasia is rare
        
        1 more item...
        
        Thymoma-associated MG
        
        Most common paraneoplastic disorder
        
        50% of patients develop positive AChR antibodies without clinical manifestations
        
        30% of patients develop MG
        
        20% of patients develop MG with thymoma
        
        Myositis, Morvan syndrome and pure red aplasia (less common)
- - - - • It is better to encourage the breastfeeding everyday either day and night and make sure the mother feed the baby as long as she/he wants .
      - • It is assure that the mother is getting helped whenever she needs the assistance but importantly is when the mother is first time, mother with special needs and an adolescent mother.
      - • Explain to the mother who is feeding the baby so that she let the baby to finish with the first breast which will come off on the own before offering second breast.
      - • The mother is encouraged to start with every each feed with a different breast..
      - • The mother is required to express the breast milk by showing the mother on how to do and show on how the expressed breast milk is feed by using a cup.
      - • We need to encourage the mother that the breast milk is enough to satisfy the baby in need for food.
      - • The mother is encourage to continue breastfeeding when she is either at work by feeding the baby more when she is at home.
      - • The mother is advised to seek medical care from the doctor if the baby is not getting the feeding well or when the mother is having any sore nipples when she is breastfeeding.
  - - - can be used safely during her pregnancy with correct dose
        
        600mg per day PO (by mouth) in divided doses
        
        intravenous anticholinesterase drug should be avoided to be given to the patient due to it might cause premature labour in pregnancy
        
        might have excreted to human milk but the amount is negligible
        
        overdose of this drug can cause a cholinergic crisis
        
        might increase the muscle weakness in patient and myasthenia crisis
        
        take the drug exactly as directed and do not take more or less of the amount of drug prescribed
        
        bromide can cause allergic reaction
    - - cause allergic reaction due to the inactive ingredients that can induced allergic reaction
        
        body become hard to response to physical stress
        
        prone to get infections so the patient should wash hand frequently and avoid contact with people that has infection
        
        use of alcohol should be avoided because this can cause stomach bleeding
        
        5-60mg per day by mouth and slowly adjusted to suitable amount
    - - can cause nausea and vomiting therefore it is recommended that the patient should take after meals
        
        temporary hair loss
        
        can cause allergic reaction
        
        cause skin cancer therefore the patient should avoid stay under the sun in a long period
        
        use sunscreen or wear protective cloth
        
        higher chance to get infection due to the immune response will be reduced so must avoid contact with people that has existing infectious diseases
        
        pregnant woman should avoid contact with this medication due to the drug can absorbed by skin as well as lungs and cause harm to infant
        
        1-3mg per kg daily and can stop taking if there is no any improvement after 3 to 6 months
    - - given via parenteral route to the patient every 6 hours and it will be slowly injected at least 30 minutes
        
        not allowed to take vaccine as this medication can cause the vaccine not working
        
        can cause an intestinal condition, normally occur during the period of patient taking this medication or several weeks to months after patient has stopped the medications
  - - - Lifestyle
        
        Getting dressed
        
        Helpful tools
        
        Rest periods
        
        Safety at home
      - Nutrition
        
        Exercise
        
        Healthy foods
        
        regain your potassium levels
        
        Medication
        
        Prednisone
        
        Bone loss
        
        eat dairy & Vit D
        
        Water retention
        
        take in less salt or avoid salt
        
        Diarrhea
        
        if happens, avoid taking dairy, spicy, fatty and fibrous food
    - - Nutrition
        
        Fat
        
        Folate
        
        Iron
        
        Protein & Carbs
        
        Zinc
        
        Vitamins
      - Formula Milk
        
        Not recommeneded as it has no antibdy from the mother but still have the sufficient amount of nutrients the baby need
        
        Breastfeeding by the mother with myasthenia gravis is safe if she is following a treatment course that utilizes pyridostigmine or corticosteroids; however, mothers with myasthenia gravis being treated with azathioprine, methotrexate, mycophenolate mofetil, or cyclophosphamide, as well as mothers of newborns with myasthenia gravis, should not breastfeed
- - - - Diagnosis: Anaphylactoid syndrome of pregnancy (ASP) / Amniotic Fluid Embolism
        
        < Respiratory insufficiency
        
        < Dyspnoea
        
        < Cardiac arrest
        
        Seizure
        
        Further clarification
        
        4 more items...
        
        Definition: Amniotic fluid enters maternal's circulation
        
        Risk factors (Case study)
        
        Older maternal age
        
        38 y/o
        
        ASP Prevalence: 35 years & above
        
        Caesarean section
        
        Higher risk of placenta become abnormally attached to uterus wall
        
        Risk is higher in pregnant women aged 35 & above
        
        Mechanism of ASP (Case study)
        
        Premature rupture of membranes
        
        Commonly known to occur 48 hours after birth (second day of postpartum period)
        
        Management of ASP
        
        Ventilatory assistance
        
        Advanced airway for immediate oxygenation
        
        Resuscitation
        
        Control cascade of symptoms
        
        Maternal Post-Resuscitation Care
        
        Targeted Temperature Management (TTM)
        
        Lowers the body temperature
        
        Why?
        
        1 more item...
        
        Temp: 32°C to 34°C (24 - 48 hours)
        
        Performed after cardiac arrest
        
        aids in
        
        Increase of mortality rate
        
        Improvement of neurologic functioning
        
        Ventilatory assistance are used daily with TTM
        
        After resuscitation & ventilatory assistance
    - - APGAR result
        
        five components - skin colour, heart rate, reflexes, muscle tone and respiration
        
        1-minute score indicates how well the baby tolerated the labour and delivery process. The 5-minute score indicates how well the infant is doing outside the mother's womb to the health care provider. The test will be done 10 minutes after birth for some rare cases.
        
        Each component of the test will be scored with 0, 1 or 2 based on the observed condition
        
        A score of 7, 8, or 9 is considered normal and indicates that the newborn is healthy. A score of ten is extremely rare, as practically every newborn loses one point due to blue hands and feet, which is normal after birth.
        
        Any score lower than 7, this indicates that the baby needs medical attention. Low APGAR score may be caused by difficulty in breathing, C-section or there is fluid in the baby’s airway
        
        1 more item...
      - In the long run
        
        Might be healthy
        
        Previous thymectomy (Case study)
        
        Reduce risk of neonatal MG
        
        Low doses of acetylcholine esterase drugs (Case study)
        
        Pyridostigmine
        
        Improves muscle strength
        
        Babies that are born to mothers that have MG are susceptible due to antibodies cross over from mother to the baby
        
        Neonatal MG - temporary form of MG, antibody-mediated disorder induced by maternal antibodies being transmitted across the placenta.
        
        symptoms disappear at weeks or months after the birth due to naturally replaced antibodies, elimination of maternal antibodies is correlated with this improvement
    - - Elevated Antibody
        
        Possible causes of autoimmune response
        
        certain viral or bacterial proteins that mimic as “self-proteins” in the body such as acetylcholine receptors
        
        Thymus, but this patient was previously thymectomized, so it is not one of the reasons of the response
        
        Complication of cesarean operation under spinal anesthesia
        
        Treatment
        
        Anticholinesterase agent - Pyridostigmine
        
        Immunosuppressant - Azathioprine and Corticosteroids
        
        Myasthenia Gravis (MG), autoantibody-mediated disease caused by antibodies circulating in the bloodstream that target skeletal muscle receptors and proteins at the neuromuscular junction (NMJ)
        
        Anti- Acetylcholine receptor antibody (AChR) (Ach-R-Ak 54.5 nmol/L, normal range <0.4 nmol/L)
      - Elevated inflammation value
        
        High C-reactive protein (CRP) value (CRP 15 mg/dL, normal range <5 mg/dL)
        
        protein formed by the liver that will enter the bloodstream upon response towards the inflammation
        
        Leukocytes level in higher than normal range (12.000/μL, normal range 4.000–9.400/μL)
        
        High white blood cells level may indicate viral or bacterial infection, inflammation and immune system disorders
        
        Computed tomography
        
        no sign of cerebral pathologies
        
        lobar pneumonia was detected
        
        focal non-segmental pneumonia, is a radiographic pattern characterised by homogeneous and fibrinosuppurative consolidation of one or more lobes of the lung as a result of bacterial pneumonia
        
        treated with beta-lactam antibiotic piperacillin and tazobactam to cure gram-positive bacterial infection such as Streptococcus pneumoniae, which is also a beta lactam resistant
- - - - Anticholinesterase
        
        MOA
        
        Pyridostigmine inhibit the cholinesterase which causes the inactivation of the neurotransmitter of Ach
        
        Reduction of Ach hydrolysis by cholinesterase
        
        Accumulation of Ach at the cholinergic synapse
        
        Functions
        
        Treat muscle weakness of MG patient
        
        Metabolism
        
        Pyridostigmine hydrolyses with the help of cholinesterase to form 3-hydroxy-N-mehyl-pyridinum(HNM)
        
        Excreted through the urine
        
        Metabolites
        
        Glucormidated
        
        Demthylated
        
        Quinone
        
        Side effects
        
        Common
        
        Stomach pain
        
        nausea
        
        Vomiting
        
        Muscle cramps
        
        Blurred Vision
        
        Adverse
        
        Sever itching
        
        Slurred speech
        
        Confusion
        
        Seizures
        
        Difficulty breathing
    - - Function
        
        suppress the immune system
      - MoA
        
        Azathioprine is a purine analog
        
        will undergo catalytic reaction
        
        Hypoxanthanine-Guanine phosphoribosyltransferase (HPRT)
        
        Mercaptiopurine (6-MP) & Thioguanine (6-TGN)
        
        inhibit purine synthesis
        
        Mediate most immunosuppressant and toxic effect
        
        Incroporated into replicating DNA and half division
        
        High polarity
        
        2 more items...
        
        Thiopurine methyltransferase (TPMT)
      - Pharmacodynamics
        
        Modulation of rac1 to induce T cell apoptosis
        
        are most active in synthesizing purine, making new DNA, these cells are most strongly affected
        
        Improving duration of action
        
        given daily
        
        narrow theapuetic index
      - Metabolism
        
        Excretion
        
        Liver
        
        Reduced excretion and also toxic if patient has renal failure
      - Side effects
        
        increased stomach irritation
        
        nausea and vomitting
        
        loss of appetite
        
        Fatigue
        
        Unusual bruising
    - - Corticosteroids
        
        Function
        
        treat the symptoms of low corticosteroid levels
        
        treat many diseases such as the types of arthritis, severe allergic reactions, multiple sclerosis,), lupus and conditions affecting the lungs, skin, eyes, kidneys, blood, thyroid, stomach, and intestines
        
        treat the symptoms of cancer
        
        MoA
        
        reduces inflammation by stopping polymorphonuclear leukocyte migration and reversing enhanced capillary permeability
        
        antiemetic properties via inhibiting prostaglandin, which blocks brain innervation of the emetic center
        
        Prednisone penetrates the nucleus, binds and activates particular nuclear receptors, resulting in altered gene expression and suppression of proinflammatory cytokine production after cell surface receptor attachment and entry into the cell
        
        Side effects
        
        headache, dizziness, acne and thin
        
        Side effects that need to contact doctor
        
        Vision problem, seizure, depression and vomiting
  - - - Function
        
        beta-lactam antibiotic which was used for the treatment of certain organism mainly the gram-positive organisms
      - MoA
        
        The bactericidal for the activity of the Piperacillin usually resulted from inhibition for the synthesis of the cell wall and it is mediated by the Piperacillin binding for the penicillin binding protein.
    - - Function
        
        used with the combination of the piperacillin which able to treat with many bacterial infections that may occur in different parts of our body such as stomach, lungs, and female reproductive organ.
        
        MoA
        
        -Tazobactam will inhibit the action for the bacterial beta-lactamases of certain organism that are usually resistant towards the beta-lactam antibiotics.
        -Tazobactam as we know contain beta-lactam ring which is destroyed by certain organisms which are beta-lactam resistant.
    - - Common
        
        Diarrhea
      - less common side effect
        
        bloating, burning of the upper abdominal or stomach pain, dizziness when getting up suddenly from either lying or sitting position and having fever.
      - Rare side effects
        
        chills, bruising, cold sweats and bone pain
- - - - No contraction of uterine muscles
        
        MG does not influence contractions or weaken uterine muscles
        
        Acetylcholine Receptors are not present
        
        Hormone Oxytocin stimulates contraction of uterine muscles
        
        produced in the hypothalamus and released by the pituitary gland
        
        Low levels of oxytocin typically causes contractions of the uterine muscles to slow down or completely stop
      - Pre-rupture of amniotic fluid sac
        
        Preterm Birth at 35 + 3 weeks
        
        caused by the intake of drugs
        
        Patient may have taken oral form of prednisone
        
        Azathioprine
    - - Prednisone
        
        thymectomy procedure helps a better long term clinical outcome, required less intake of prednisone, lower alternate-day prednisone doses
        
        Severity of MG is decreased
        
        intake oral form of corticosteroids increases chances of pre-term delivery
        
        Rare risks
      - Pyridostigmine Bromide
        
        Function: increase the strength of muscles
        
        Patient shows no muscular weakness due to this inhibitor
        
        safe to take during pregnancy
        
        rare case of microcephaly
        
        take the right dose to avoid possible complications
        
        600 mg/day
        
        no indication that there is a higher risk of deformity or other negative pregnancy outcomes
      - Azathioprine
        
        should be discontinued or reduced to a minimum
        
        Possible harm to fetus
        
        However, Infant in the case is born healthy
        
        Rare risks
        
        Intrauterine Impairment
        
        Effects of risk are difficult to identify
        
        Low Birth Weight
        
        Immunological alterations
        
        Preterm delivery
        
        Septal defects
    - - women who have not had a thymectomy have a higher rate of risk during pregnancy
      - advised to have their thymectomy before pregnancy
      - infants born had a lower probability of acquiring neonatal MG
  - - - The possibility of getting NMG
        
        10% of infants born to mothers with MG have NMG
        
        NMG occurs in any of the MG subgroups
        
        mother with
        
        both AChR and MuSK antibodies
        
        undetectable MuSK antibodies
      - signs and symptoms
        
        at birth
        
        no symptoms
        
        12 hours to 4 days of life
        
        may be delayed onset
        
        difficulty in breathing
        
        ptosis
        
        poor sucking
        
        hypotonia
        
        weak cries
        
        After 4 weeks
        
        1 more item...
      - due to
        
        the presence of high affinity of embryonic AChR antibodies
        
        high ratio of anti-embryonic AChR to anti-adult AChR in the mother
        
        transplacental transfer of antibodies against AChR, MuSK or LRP4
  - - - Complication of c-sect
        
        Infection
        
        post-caesarean wound infection
        
        may lead to death (uncommon)
        
        can be aggresive
        
        can spread to other organs
        
        endometritis
        
        rupture of the amniotic sac
        
        60% and 70% caused by
        
        aerobes bacteria
        
        infect
        
        1 more item...
        
        anaerobes bacteria
        
        bacteria colonise devitalized, bleeding or uterine tissue
        
        reaction to anaesthesia
        
        sensory and motor block
        
        high level spinal blockade + anticholinesterase
        
        vagal response
        
        anaesthesia management
        
        induction and maintenance of anaesthesia
        
        avoid from prolonged effects on respiratory and bulbar muscles
        
        anaesthetic technique
        
        spinal anaesthesia (neuraxial anaesthesia)
        
        disadvantage
        
        may cause paralysis of accessory muscles of breathing
        
        avoid from using neuromuscular blocking agents (NMBAs)
        
        non-depolarizing NMBAs
        
        depolarizing NMBAs