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• Associate Professor of Anesthesiology
• Program Director, Fellowship in Cardiothoracic Anesthesiology
• Mount Sinai School of Medicine
• New York, New York

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Maternal danger components for anesthesia are: Short stature muscle relaxant cz 10 buy nimodipine 30mg visa, brief neck spasms in abdomen buy 30 mg nimodipine otc, marked weight problems spasms around heart order nimodipine 30 mg without prescription, severe preeclampsia spasms on left side of body generic 30 mg nimodipine overnight delivery, bleeding disorders, placenta previa, medical disorders, like cardiac, respiratory and neurological illness. Hypothalamus controls the uterine activity by way of the reticular formation which balances the effects of the two autonomic divisions. Motor nerve provide: the uterus receives both sympathetic and parasympathetic nerve fibers. The sympathetic nerve fibers arise from lower thoracic and higher lumbar segments of the spinal twine. The parasympathetic fibers come up from sacral 2, 3 and four segments of the spinal cord. The preganglionic fibers of the sympathetic nerves arising from the spinal twine cross through the ganglia of the sympathetic trunk to aorticorenal plexus the place they synapse. The aorticorenal plexus continues as the superior hypogastric plexus or presacral nerve and passes over the bifurcation of aorta and divides into proper and left hypogastric nerves. Each hypogastric nerve joins the pelvic parasympathetic nerve of the corresponding aspect and forms the pelvic plexus (right and left) or inferior hypogastric plexus. The pelvic plexus then continues alongside the course of the uterine artery as paracervical plexus on all sides of the cervix. Sensory pathway: Sensory stimuli from the uterine body are transmitted by way of the pelvic, superior hypogastric and aorticorenal plexus to the tenth, eleventh and 12th dorsal and the primary lumbar segments of the spinal cord. Sensory stimuli from cervix pass through the pelvic plexus alongside the pelvic parasympathetic nerves to sacral segments 2, three and 4 of the spinal twine. Sensory stimuli from higher vagina pass to 2, three and four sacral parasympathetic segments and from lower vagina pass through the pudendal nerve. The perineum receives both motor and sensory innervation from sacral roots 2, three and 4 by way of the pudendal nerve. The branches of ilioinguinal and genital branch of genitofemoral nerves provide the labia majora and in addition carry the impulses from the perineum. It is believed that some hormones are essential for the control of uterine exercise. Oxytocin, a hormone derived from posterior pituitary maintains the uterine activity throughout labor. Adrenaline with its beta exercise inhibits the contraction of uterus, whereas its alpha exercise excites it. During cesarean delivery incision is often made around the T12 dermatome anesthesia is required from the extent of T4 to block the peritoneal discomfort. Labor ache is experienced by most girls with satisfaction on the finish of a profitable labor. Antenatal (mothercraft) lessons, sympathetic care and encouraging surroundings throughout labor can reduce the necessity of analgesia. The intensity of labor ache is dependent upon the depth and length of uterine contractions, degree of dilatation of cervix, distension of perineal tissue, parity and the ache threshold of the subject. The most distressing time during the entire labor is simply prior to full dilatation of the cervix. Some sufferers experience extreme pain though the uterine contractions are relatively weak. For the purpose of choosing a common analgesic drug, labor has been divided arbitrarily into two phases. The first phase corresponds up to 8 cm dilatation of the cervix in primigravidae and 6 cm in case of multipara. The second section corresponds to dilatation of the cervix beyond the above limits as much as delivery. The first section is managed by sedatives and analgesics, and the second section is controlled by inhalation agents. OpiOid analgesics-pethidine: For a long time pethidine has been used as an analgesic in labor. Pethidine is usually used in the early first stage of labor and indicated when the discomfort of labor merges into regular, frequent and painful contractions. The side effects of pethidine to the mother are nausea, vomiting, delayed gastric emptying. Pethidine reduces baseline variability, depresses respiration and suckling of the newborn when administered earlier than supply. Meperidine: Compared to morphine, analgesic effect is one tenth, but respiratory depression effect is much less. Phenothiazines: Promethazine (phenergan) is usually utilized in labor in combination with an opioid. Narcotic antagonists are used to reverse the respiratory despair induced by opioid narcotics. Naloxone is given to a newborn born of a narcotic addicted mother, with proper ventilation arrangement only in any other case withdrawal signs are precipitated. Major disadvantages are: Loss of beat to beat variability in labor, neonatal hypotonia and hypothermia. Combination of narcotics and antiemetics: Narcotics may be utilized in combination with promethazine, metoclopramide or ondansetron. The advantages claimed that the mix potentiates the action of narcotic, produces much less respiratory depression and prevents vomiting. But there are additionally disadvantages like hypotension and delay of second stage of labor. This agent is used within the second phase (from 8 cm dilatation of cervix to delivery). The lady is to take slow and deep breaths before the contractions and to cease when the contractions are over. It offers sensory in addition to numerous degrees of motor blockade over a region of the body. But anesthetists/obstetricians have to be skilled correctly to make use of this very useful technique in regular and irregular labor. Continuous lumbar epidural block: A lumbar puncture is advantages of Regional anesthesia made between L2 and L3 with the epidural needle (Tuohy needle). The patient is awake and might enjoy the With the affected person on her left aspect, the again of the patient is cleansed start time with antiseptics earlier than injection. Epidural analgesia, as a basic rule should be given when labor is nicely established. Epidural analgesia is especially helpful in cases like pregnancy-induced hypertension, breech presentation, twin being pregnant and preterm labor. This may lead to frequent need of instrumental supply like forceps or ventouse. Back ache Postspinal headache because of leakage of cerebrospinal uid by way of the needle hole within the dura Total spinal due to inadvertent administration of the drug within the subarachnoid house Injury to nerves, convulsions, pyrexia Ine ective analgesia Supine hypotension Hypovolemia Neurological illnesses Spinal deformity or continual low back pain Skin an infection at the injection web site Paracervical nerve block: Is useful for pain reduction in the course of the first stage of labor. This dose is quite sufficient to relieve pain for about an hour or two, and injections may be given greater than once if essential. Paracervical block can only relieve the pain of uterine contraction and the perineal discomfort is eliminated by pudendal nerve block.

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This vesicle muscle relaxant 751 buy nimodipine 30mg with visa, referred to as a phagosome spasms behind knee discount nimodipine 30mg fast delivery, contains the ingested overseas particle muscle relaxant 2631 generic nimodipine 30 mg amex, and it breaks away from the plasma membrane spasms multiple sclerosis order nimodipine 30 mg on line. The cell floor receptors also deliver activating signals that stimulate the microbicidal actions of phagocytes. At the identical time, peptides are generated from microbial proteins and offered to T lymphocytes to initiate adaptive immune responses (see Chapter 6). Activated neutrophils and macrophages kill phagocy tosed microbes by the motion of microbicidal molecules in phagolysosomes. Fusion of phagocytic vacuoles (phagosomes) with lysosomes ends in the formation of phagolysosomes, where many of the microbicidal mechanisms are concentrated. Activated neutrophils and macrophages produce a number of proteolytic enzymes within the phagolysosomes that perform to destroy microbes. One of the necessary enzymes in neutrophils is elastase, a broad-spectrum serine protease recognized to be required for killing many types of micro organism. Mouse gene knockout research have confirmed the important requirement for these enzymes in phagocyte killing of micro organism. Superoxide is enzymatically dismutated into hydrogen peroxide, which is used by the enzyme myeloperoxidase to convert usually unreactive halide ions into reactive hypohalous acids which are poisonous for bacteria. A disease referred to as continual granulomatous disease is attributable to an inherited deficiency of one of the parts of phagocyte oxidase; this deficiency compromises the capacity of phagocytes to kill sure species of micro organism (see Chapter 21). Within phagolysosomes, nitric oxide may mix with hydrogen peroxide or superoxide, generated by phagocyte oxidase, to produce highly reactive peroxynitrite radicals that may kill microbes. Other Functions of Activated Macrophages In addition to killing phagocytosed microbes, macrophages serve many other capabilities in defense in opposition to infections. Some activated macrophages additionally produce progress elements for fibroblasts and endothelial cells that take part within the restore of tissues after infections and harm. Macrophages could also be activated in different methods, which favor microbicidal and proinflammatory features or, in distinction, reparative and antiinflammatory features. These different sorts of macrophage activation, referred to as classical and alternative, respectively, are mentioned in more element in Chapter 10. The process of macrophage activation leads to the activation of transcription factors, the transcription of assorted genes, and the synthesis of proteins that mediate the functions of these cells. Macrophages additionally may be activated by other signals to promote tissue repair and fibrosis (not shown). Prostaglandin synthesis inhibitors, similar to aspirin, reduce fever by blocking this motion of the cytokines. Elevated plasma ranges of those proteins are commonly used clinically as indicators of infection or other inflammatory processes. The endothelial alterations are exacerbated by activation of neutrophils, resulting in vascular plugging by these cells. A syndrome similar to septic shock might happen as a complication of noninfectious problems, such as severe burns, trauma, pancreatitis, and other serious circumstances. Acute inflammation could cause tissue damage as a outcome of the effector mechanisms that phagocytes use to kill microbes are also toxic to host tissues. In truth, at least part of the pathology associated with infections is because of the inflammatory responses and not the direct poisonous results of the microbes. Acute irritation also causes tissue harm within the setting of autoimmune diseases, by which case neutrophils and macrophages accumulate and turn into activated on account of stimulation of the adaptive immune system by self antigens (see Chapter 15). Antagonists against all of these cytokines or their receptors are in clinical use to reduce inflammation in patients with inflammatory ailments corresponding to rheumatoid arthritis, inflammatory bowel disease, and psoriasis. These sort I interferons are secreted from the cells and act on other cells to stop the unfold of viral an infection. Type I interferons are a big family of structurally associated cytokines that mediate the early innate immune response to viral infections. The term interferon derives from the flexibility of these cytokines to intervene with viral infection. There are many kind I interferons, that are structurally homologous and are encoded by genes in a single cluster on chromosome 9. Interferon secreted by an contaminated cell may act in an autocrine trend to inhibit viral replication in that cell. Type I interferons cause sequestration of lymphocytes in lymph nodes, thus maximizing the chance for encounter with microbial antigens. These results of type I interferons improve both innate and adaptive immunity against intracellular infections, including viruses and some bacteria. Thus, the principal actions of kind I interferon work in live performance to fight viral infections. Knockout mice lacking the receptor for sort I interferons are vulnerable to viral infections. Lymphocyte Antigen receptor Microbial antigen Innate immune response to microbe Molecule induced by innate response. As the innate immune response is providing the initial defense in opposition to microbes, it additionally sets in movement the adaptive immune response. The activation of lymphocytes requires two distinct indicators, the first being antigen and the second being molecules which are produced during innate immune responses to microbes or injured cells. The molecules produced during innate immune reactions that operate as second indicators for lymphocyte activation embody costimulators (for T cells), cytokines (for each T and B cells), and complement breakdown merchandise (for B cells). We will return to the nature of second signals for lymphocyte activation in Chapters 9 and 12. The second signals generated throughout innate immune responses to totally different microbes not only enhance the magnitude of the next adaptive immune response but also affect the character of the adaptive response. A main perform of T cell�mediated immunity is to activate macrophages to kill intracellular microbes and to induce strong inflammatory responses in order that a sufficiently giant military of phagocytes is known as into a site of an infection. Antigen recognition by lymphocytes supplies sign 1 for the activation of the lymphocytes, and molecules induced on host cells during innate immune responses to microbes present sign 2. In this illustration, the lymphocytes are B cells, but the identical rules apply to T lymphocytes. The nature of second signals differs for B and T cells and is described in later chapters. These antibodies opsonize the microbes and thereby promote their phagocytosis by neutrophils and macrophages, or kill the microbes by complement-dependent mechanisms. Cytokines produced by cells throughout innate immune responses to microbes stimulate the proliferation and differentiation of lymphocytes in adaptive immune responses. We have mentioned these cytokines previously and will discuss the major points of their roles in lymphocyte responses in later chapters. Mechanisms That Limit Innate Immune Responses ninety three Adjuvants are substances that have to be administered together with purified protein antigens to elicit maximal T cell�dependent immune responses (see Chapter 6). The solely routinely used adjuvant in human vaccines is alum, which is composed of both aluminum hydroxide or aluminum phosphate, and is a stimulus for inflammasome activation. Whereas the inflammatory response is critically important for protection against microbes, it has the potential to trigger tissue injury and disease.

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The bleeding is often revealed however can rarely be concealed (vulvovaginal or broad ligament hematoma) spasms below left breast generic nimodipine 30mg with mastercard. The blood coagulopathy could additionally be because of muscle relaxant home remedy order nimodipine 30 mg amex diminished procoagulants (washout phenomenon) or increased fibrinolytic activity spasms during pregnancy nimodipine 30 mg lowest price. Rarely muscle relaxant 1 order nimodipine 30 mg on-line, the bleeding is completely concealed as both vulvovaginal or broad ligament hematoma. The effect of blood loss depends on-(a) Predelivery hemoglobin degree, (b) degree of pregnancy induced hypervolemia and (c) velocity at which blood loss happens. Alteration of pulse, blood stress and pulse strain seems solely after class 2 hemorrhage (20�25% loss of blood volume). On event, blood loss is so speedy and brisk that demise could occur within a couple of minutes. State of uterus, as felt per abdomen, provides a reliable clue as regards the cause for bleeding. Even following massive blood loss from the injured space, a state of low basic situation could make the uterus atonic. It is amongst the main causes of maternal deaths each within the growing and developed international locations (see p. Prevalence of malnutrition and anemia, insufficient antenatal and intranatal care and lack of blood transfusion amenities, substandard care are a few of the necessary contributing components. These embrace shock, transfusion response, puerperal sepsis, failing lactation, pulmonary embolism, thrombosis and thrombophlebitis. Antenatal Improvement of the health status of the girl and to hold the hemoglobin stage normal (> 10 g/dL) in order that the affected person can stand up to some quantity of the blood loss. Blood grouping should be carried out for all girls so that no time is wasted throughout emergency. Placental localization must be accomplished in all girls with earlier cesarean delivery (see p. Cases with induced or augmented labor by oxytocin, the infusion ought to be continued for at least one hour after the delivery. Exploration of the uterovaginal canal for evidence of trauma following troublesome labor or instrumental supply. Observation for about two hours after supply to make sure that the uterus is hard and properly contracted earlier than sending her to ward. Expert obstetric anesthetist is needed when the supply is conducted under common anesthesia. Local or epidural anesthesia is preferable to general anesthesia, in forceps, ventouse or breech delivery. During cesarean section spontaneous separation and delivery of the placenta reduces blood loss (30%). Examination of the placenta and membranes ought to be a routine to detect at the earliest any missing part. The massage is to be accomplished by putting four fingers behind the uterus and thumb in entrance. However, if bleeding continues even after the uterus becomes onerous, suggests, the presence of genital tract damage. Carbetocin, a longer acting oxytocin by-product is discovered (100 �g) as efficient as oxytocin infusion. During this procedure, if features of placental separation are evident, expression of the placenta is to be done either by fundal pressure or managed wire traction method. However, if the affected person is in shock, she is resuscitated first earlier than endeavor handbook removing. If the patient is delivered underneath basic anesthesia, fast manual removing of the placenta solves the problem. While introducing the hand, the labia are separated by the fingers of the other hand. The stomach hand should regular the fundus and guide the movements of the fingers contained in the uterine cavity till the placenta is totally separated. The placenta is steadily separated with a sideways slicing motion of the fingers, till complete of the placenta is separated. The uterine hand is still contained in the uterus for exploration of the cavity to be sure that nothing is left behind. After the completion of manual elimination, inspection of the cervicovaginal canal is to be made to exclude any injury. Difficulties: (1) Hour-glass contraction leading to issue in introducing the hand, (2) Morbid adherent placenta which can cause difficulty in getting to the plane of cleavage of placental separation. Complications: (1) Hemorrhage due to incomplete removing, (2) Shock, (3) Injury to the uterus, (4) Infection, (5) Inversion (rare), (6) Subinvolution, (7) Thrombophlebitis, (8) Embolism. In such cases placenta is eliminated in fragments using an ovum forceps or a flushing curette. Infuse rapidly 2 liters of regular saline (crystalloids) or plasma substitutes like Haemaccel (colloids), an urea-linked gelatin, to reexpand the vascular bed. One midwife/rotating houseman ought to be assigned to monitor the following-(i) Pulse (ii) Blood pressure (iii) Temperature (iv) Respiratory price and oximeter (v) Type and amount of fluids (blood, blood products) the patient has acquired (vi) Urine output (continuous catheterization) (vii) Drugs-type, dose and time (viii) Central venous pressure (when sited). Simultaneous inspection of the cervix, vagina particularly the paraurethral area is to be carried out to exclude coexistent bleeding websites from the injured area. Procedures: (a) the entire hand is launched into the vagina in cone shaped fashion after separating the labia with the fingers of the opposite hand, (b) the vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in the anterior fornix, (c) the other hand is positioned over the abdomen behind the uterus to make it anteverted, (d) the uterus is firmly squeezed between the 2 hands. It could also be necessary to proceed the compression for a chronic interval until the tone of the uterus is regained. If, regardless of therapy, the uterus stays refractory and the bleeding continues, the potential of blood coagulation problems should be stored in mind and large fresh entire blood transfusion ought to be given until specific measures could be employed. But in rare circumstances, when the uterus fails to contract, the following could also be tried desperately as an fig. The gauze is placed high up and packed into the fundal space first while the uterus is steadied by the external hand. Gradually, the remainder of the cavity is packed in order that no empty house is left behind. Intrauterine plugging acts not solely by stimulating uterine contraction but exerts direct hemostatic pressure (tamponade effect) to the open uterine sinuses. Intrauterine packing is helpful in a case of uncontrolled postpartum hemorrhage where different strategies have failed and the affected person is being prepared for transport to a tertiary care center. Foley catheter, Bakri balloon, Condom catheter or Sengstaken-Blakemore tube is inserted into the uterine cavity and the balloon is inflated with normal saline (200�500 mL). It is successful in atonic Chapter 28 Complications of the Third Stage of Labor 481 482 Textbook of Obstetrics fig.

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Variable regions are so named as a end result of their amino acid sequences range among antibodies made by different B cell clones spasms 14 year old beagle buy nimodipine 30 mg on-line. Because the core structural unit of each antibody molecule contains two heavy chains and two light chains muscle relaxer 75 purchase 30mg nimodipine amex, each antibody molecule has no less than two antigen-binding websites spasms icd 9 code purchase 30 mg nimodipine with amex. The heavy chain C regions work together with different molecules and cells of the immune system and subsequently assist mediate a lot of the biologic capabilities of antibodies muscle relaxant rub generic nimodipine 30 mg line, generally referred to as "effector" features. In addition, heavy chains exist in two types that differ at their carboxy-terminal ends: one type of the heavy chain anchors membrane-bound antibodies in the plasma membranes of B lymphocytes, and the other kind is found only in secreted antibodies. The two heavy chains of every antibody molecule are also covalently linked by disulfide bonds. There are different sorts of antibodies, known as classes or isotypes, which have completely different heavy chain buildings, discussed intimately later within the chapter. If rabbit IgG is treated with the enzyme papain underneath conditions of limited proteolysis, the enzyme acts on the hinge region and cleaves the IgG into three separate pieces. This piece of IgG has a propensity to self-associate and to crystallize right into a lattice, and is due to this fact called Fc (fragment, crystallizable). When pepsin (instead of papain) is used to cleave rabbit IgG under limiting situations, proteolysis occurs distal to the hinge region, producing a F(ab)2 fragment of IgG with the hinge and the interchain disulfide bonds intact and two similar antigen-binding websites. The fundamental group of the antibody molecule deduced from the rabbit IgG proteolysis experiments is frequent to all Ig molecules of all classes and all species, and the phrases Fab, F(ab)2, and Fc are extensively used to describe these different portions of human and mouse antibodies. In truth, these experiments offered the first evidence that the antigen recognition capabilities and the effector functions of Ig molecules are spatially separated. Rabbit IgG molecules are cleaved by the enzymes papain (A) and pepsin (B) on the sites indicated by arrows. Papain digestion permits separation of two antigen-binding regions (the Fab fragments) from the portion of the IgG molecule that binds to complement and Fc receptors (the Fc fragment). All molecules that include this kind of area are mentioned to belong to the Ig superfamily, and all gene segments encoding the Ig domains of those molecules are believed to have evolved from one ancestral gene. Ig domains are classified as V-like or C-like on the idea of closest homology to both Ig V or Ig C domains. V domains are shaped from a longer polypeptide than C domains and contain two further strands throughout the sheet sandwich. Examples of Ig superfamily members of relevance within the immune system are depicted in. Structural Features of Antibody Variable Regions Most of the sequence differences and variability amongst different antibodies are confined to three short stretches in the V area of the heavy chain and to three stretches in the V region of the light chain. They correspond to three protruding loops connecting adjacent strands of the sheets that make up the V domains of Ig heavy and light chain proteins. The hypervariable loops could be thought to resemble fingers protruding from every variable domain, with three fingers from the heavy chain and three fingers from the sunshine chain coming together to type the antigen-binding site. Confinement of the sequence variability to three short stretches allows the fundamental construction of all antibodies to be maintained despite the variability of specificities among totally different antibodies. A, the vertical lines depict the extent of variability, outlined as the variety of variations in every amino acid residue amongst varied independently sequenced Ig gentle chains, plotted in opposition to amino acid residue quantity, measured from the amino terminus. This method of displaying amino acid variability in Ig molecules is identified as a Kabat-Wu plot after the 2 scientists who devised the assay. Heavy chain hypervariable regions (not shown) are also located in three loops, and all six loops are juxtaposed in the antibody molecule to kind the antigen-binding surface. Kabat, Department of Microbiology, Columbia University College of Physicians and Surgeons, New York. B, this mannequin of a globular protein antigen (hen egg lysozyme) sure to an antibody molecule shows how the antigen-binding website can accommodate soluble macromolecules of their native (folded) conformation. The heavy chains of the antibody are pink, the sunshine chains are yellow, and the antigen is blue. The residues of hen egg lysozyme and of the Fab fragment that interact with each other are proven in purple. A important glutamine residue on lysozyme (in magenta) matches into a "cleft" in the antibody. Structural Features of Antibody Constant Regions Antibody molecules may be divided into distinct lessons and subclasses on the basis of variations within the construction of their heavy chain C regions. The courses of antibody molecules are additionally referred to as isotypes and are named IgA, IgD, IgE, IgG, and IgM (Table 5. In people, IgA and IgG isotypes could be further subdivided into closely associated subclasses, or subtypes, known as IgA1 and IgA2 and IgG1, IgG2, IgG3, and IgG4. Heavy chains are designated by the letter of the Greek alphabet similar to the isotype of the antibody: IgA1 accommodates 1 heavy chains; IgA2, 2; IgD,; IgE,; IgG1, 1; IgG2, 2; IgG3, 3; IgG4, four; and IgM, �. Different isotypes and subtypes of antibodies perform completely different effector capabilities. Antibody isotypes and subtypes differ of their C regions and due to this fact in what they bind to and what effector features they perform. Antibody molecules are versatile, allowing them to bind to totally different arrays of antigens. Many Ig molecules can orient these binding sites so that two antigen molecules on a planar. The hinge region varies in length from 10 to greater than 60 amino acid residues in different isotypes. Some of the greatest differences between the constant areas of the IgG subclasses are concentrated within the hinge. There are two lessons, or isotypes, of sunshine chains, referred to as and, that have distinct carboxy-terminal constant (C) areas. Each antibody molecule has both two identical light chains or two similar mild chains. In people, about 60% of antibody molecules have light chains, and about 40% have mild chains. The two antigen-binding sites of an Ig monomer can concurrently bind to two determinants separated by varying distances. In (A) an Ig molecule is depicted binding to two extensively spaced determinants on a cell surface, and in (B) the same antibody is binding to two determinants which are shut collectively. In reality, an abnormal predominance of either -bearing cells or -bearing cells is often used clinically for the prognosis of B cell lymphomas. In mice, -containing antibodies are about 10 occasions extra ample than -containing antibodies. Secreted and membrane-associated antibodies differ in the amino acid sequence of the carboxy-terminal end of the heavy chain C region. The secreted type, present in blood, mucosal secretions, and different extracellular fluids, contains a carboxy-terminal hydrophilic area known as the tail piece.

Diseases

• Glossophobia
• Hypertrophic hemangiectasia
• Short limb dwarfism Al Gazali type
• Follicular lymphoreticuloma
• Continuous spike-wave during slow sleep syndrome
• Spastic paraplegia familial autosomal recessive form
• Torsades de pointes
• Albright Turner Morgani syndrome

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Gonadotrophs (gonadotropes or delta basophils) produce two forms of hormones each type having a separate action in the female and male muscle relaxant pictures cheap nimodipine 30 mg line. In the feminine muscle relaxant 1 nimodipine 30 mg generic, the second hormone stimulates the maturation of the corpus luteum and the secretion by it of progesterone muscle relaxer 800 mg generic nimodipine 30 mg without prescription. The secretion of hormones by the cells of the adenohypophysis is under the management of the hypothalamus spasms from coughing generic nimodipine 30 mg fast delivery. Chromophobe Cells the chromophobe cells most likely characterize alpha or beta cells that have been depleted of their granules. Chapter 46 Endocrine Glands of the Head and Neck, Carotid Sinus and Carotid Body the Pars Posterior 1011 1. Theaxons descending into the pars posterior from the hypothalamus end in terminals intently associated to capillaries. The pars posterior of the hypophysis is related to the release into the blood of two hormones. The second hormone is oxytocin: this hormone controls the contraction of easy muscle of the uterus and in addition of the mammary gland. They are synthesised in neurons positioned primarily within the supraoptic and paraventricular nuclei of the hypothalamus. Vasopressin is produced mainly in the supraoptic nucleus; and oxytocin within the paraventricular nucleus. These secretions (which are bound with different proteins) pass down the axons of the neurons concerned, by way of 46. The hypophysis cerebri is equipped by superior and inferior branches arising from the inner carotid arteries. Branches from the superior set of arteries provide the median eminence and infundibulum. These portal vessels descend by way of the infundibulum and end in the sinusoids of the pars anterior. It will be observed that the above arrangement is uncommon in that two units of capillaries intervene between the arteries and veins. The second set of capillaries is represented by the sinusoids of the pars anterior. The secretion of hormones by the adenohypophysis takes place beneath larger control of neurons in the hypothalamus, notably those within the median eminence and within the infundibular nucleus. The axons of those neurons finish in relation to capillaries in the median eminence and in the upper a part of the infundibulum. Different neurons produce specific releasing elements (or releasing hormones) for each hormone of the adenohypophysis. Portal vessels arising from the capillaries carry these elements to the pars anterior of the hypophysis. The effects of the tumour (adenoma) could also be caused by pressure on surrounding buildings, or by elevated or decreased manufacturing of hormones. An adenoma arising from chromophobe cells can turn into quite massive and might produce stress results as follows. Pressure on the partitions of the hypophyseal fossa (sella turcica) results in its enlargement, and this enlargement may be seen in a skiagram. Pressure on the optic chiasma can result in lack of vision within the temporal halves of vision in each eyes (bitemporal hemianopia). The method could be through the roof of the pharynx, through the sphenoidal sinuses. In extensive tumours, the cranial cavity has to be opened so that the tumour may be seen directly. Chapter forty six Endocrine Glands of the Head and Neck, Carotid Sinus and Carotid Body 1013 a. In a young particular person (before the epiphyses have fused), the situation leads to excessive development (gigantism). If the adenoma is shaped after the epiphyses have fused, overgrowth mainly impacts the pinnacle, the hands and the feet (acromegaly). The scalp, lips, tongue and face turn into thick due to elevated quantity of subcutaneous tissue, and the same occurs to the palms and feet. The resultant dehydration results in excessive thirst (polydipsia) and to dryness of pores and skin. Apart from stress by a tumour diabetes insipidus could be attributable to trauma to the area. The pineal body is a small piriform construction present in relation to the posterior wall of the third ventricle of the mind. It is located within the median plane just below the splenium of the corpus callosum, and just above the superior colliculi of the midbrain (46. In the adult, sections of the pineal gland present aggregations of salts containing calcium. The pineal physique has for long been regarded as a vestigial organ of no useful significance. Recent investigations have shown that the pineal physique is an endocrine gland of great significance. The finest recognized hormone of the pineal body is the amino acid melatonin (so referred to as because it causes modifications in pores and skin color in amphibia). The pineal physique may act as a type of biological clock which will produce circadian rhythms (variations following a 24 hour cycle) in various parameters. This can harm the oculomotor nucleus and can thus lead to paralysis of the oculomotor nerve. The thyroid gland lies within the front of the neck, in entrance of the lower part of the larynx and the higher a part of the trachea (46. It consists of right and left lobes that are joined, across the midline, by an isthmus (46. The vertical diameter of every lobe is about 5 cm (2 inches) and that of the isthmus is about 1 cm (half inch). Parts of two muscular tissues: the inferior constrictor of the pharynx, and the cricothyroid. Two important nerves: the recurrent laryngeal nerve and the external laryngeal nerve. The recurrent laryngeal nerve is deep to the thyroid because it ascends within the groove between the trachea and oesophagus; whereas the external laryngeal nerve lies deep to the thyroid as it descends to attain the cricothyroid (46. The lateral and medial surfaces of the lobe are separated by a sharp anterior border. Chapter forty six Endocrine Glands of the Head and Neck, Carotid Sinus and Carotid Body 1015 eleven. The posterior and medial surfaces of the lobe are separated by the posterior border which is rounded. The upper end of every lobe extends as much as the oblique line of the thyroid cartilage (46. The isthmus of the thyroid gland lies in entrance of the second, third and fourth rings of the trachea.

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The choice of antibiotic will depend on the sensitivity check but before the report is on the market spasms all over body generic nimodipine 30mg line, broad spectrum antibiotics masking Gram-positive muscle relaxant for alcoholism discount 30mg nimodipine mastercard, Gram-negative and anaerobic organisms ought to be began muscle relaxant machine nimodipine 30mg for sale. Intravenous fluids and electrolytes: Septic shock associated with hemorrhagic hypotension must be treated by liberal infusion and blood transfusion muscle relaxant baclofen safe 30 mg nimodipine. Alternatively, a tough calculation of the amount of fluid to be administered can be assessed by the volume of urinary output and its specific gravity. Oliguria with high specific gravity is a sign for liberal fluid administration, whereas a low specific gravity indicates fluid restriction. Bicarbonate ought to be administered to right persistent metabolic acidosis (pH < 7. Further doses will rely upon the clinical state of the patient and blood fuel evaluation outcome. Adrenaline, noradrenaline, dopamine and dobutamine have each inotropic and vasoconstrictive effects. Its main motion is on -adrenoreceptors, increasing cardiac contractility and cardiac output with out change in price. In a dose of 1-3 �g Kg�1 min�1 it increases renal cortical plasma circulate and glomerular filtration. Diuretic remedy: To reduce fluid overload (preload) and pulmonary edema, diuretics should be used. Corticosteroids: Patients with extreme sepsis develop systemic inflammatory response syndrome (see p. The dose beneficial in septic shock is 50 mg of hydrocortisone per kg body weight. The advantages claimed are: (i) exerts an anti-inflammatory effect at the mobile degree (ii) stabilizes lysosomal membrane (iii) counteracts anaerobic oxidative mechanism (iv) improves the regional blood flow (microcirculation) and thereby reverse the metabolic acidosis (v) exerts constructive inotropic effect to improve cardiac efficiency and (vi) some vasopressor effect. Treatment of myocarditis: Myocarditis most often is associated with septic hypotension. Elimination of source of an infection: Surgical intervention ought to be accomplished to get rid of the source of infection. Evacuation of the retained products of conception or hysterectomy for a case with septic abortion or puerperal sepsis must be accomplished directly. Hysterectomy has been advocated in unresponsive endotoxic shock following septic abortion or puerperal sepsis. Intensive insulin remedy is done in patients with extreme sepsis and septic shock to keep regular blood glucose degree. These patients often develop hyperglycemia which further will increase the risk of septicemia and death. Recombinant human-activated protein C therapy (Drotrecogin Alfa): Activated protein C is one endogenous protein that inhibits irritation, thrombosis and promotes fibrinolysis. It reduces mortality in sufferers with severe sepsis because it reduces coagulopathy and irritation. These functions may be adequately maintained offered the blood supply to the organs and the functional integrity of the nephrons (units of the kidney) remain sufficient. The possible elements are: (1) Diminished variety of septic abortion with liberalization of abortion legal guidelines (2) Judicious and early termination in extreme preeclampsia (3) Better understanding of the pathophysiology and management of shock (4) Appropriate management of abruptio placenta (5) Facilities of blood transfusion. There is significant physiological and anatomical changes within the kidney throughout being pregnant (p. In severe ischemia, renal cortical tissue is damaged and this pathology is irreversible. Microscopically, the renal tubules endure ischemic degeneration and necrosis and are blocked with casts and pigments. Provided the tubules have enough blood supply, the epithelium will slowly regenerate and the renal perform will often return to normal in 1-2 weeks whether it is taken care of in time. A narrow band of cortex instantly beneath the capsule and a portion in the region of the junction of cortex and medulla are the only parts of the cortex to survive. These parts derive their blood provide from sources other than the standard afferent glomerular vessels which undergo hyaline degeneration. The glomerular afferent vessels are end arteries and thus the injury that occurs in the phase of the nephron equipped by these arteries is irreversible, hence the last word fatality. Then the affected person looks toxic; blood stress is raised and stomach turns into distended. Still untreated�the affected person turns into drowsy, has Cheyne-Stokes respiration with dry, furred tongue, twitching of muscular tissues and mental confusion. Blood biochemical adjustments: There is gradual rise in the concentration of plasma urea, potassium, creatinine and phosphate as a outcome of endogenous protein catabolism. The rise in plasma potassium is aggravated by the retention of hydrogen ions which are compelled into the cells in change of intracellular potassium ions. The plasma concentration of bicarbonate diminishes as acidosis happens which is due to shifting of hydrogen ions intracellularly. The fall in calcium and rise in potassium stage have gotten a combined antagonistic effect on the cardiac function which may cause demise. A simultaneous rise of plasma magnesium potentiates the harmful effect of rising plasma potassium. Blood: Leukocytosis may be evident and is a better index of an infection than the rise of Urine: Physical examination reveals scanty and darkish coloured urine. Specific gravity is 1020 or extra in prerenal causes and 1010 or less in renal causes. Blood biochemical findings: Urine sodium focus is < 10 mmol/L in prerenal and > 20 mmol/L in renal causes. Urine osmolality is more than 500 m osmol/L in prerenal and fewer than 350 m osmol/L in renal causes. The causes of diuresis are: (1) Osmotic diuresis because of high blood urea (2) Functional inadequacy of tubular reabsorption (3) Release of surplus fluid and electrolytes, significantly sodium and potassium. The focus of the electrolytes both within the plasma or within the urine progressively returns to regular values and so also the specific gravity of the urine. The possibility of inadvertent damage to the ureters in susceptible circumstances also wants to be excluded. Forced diuresis Mannitol: 100 mL of 20% mannitol is administered intravenously slowly taking a minimal of 10 minutes. Mechanism: (1) Lowers blood viscosity and renal vascular resistance (2) Dilates the afferent glomerular arterioles by lowering endothelial cell swelling (3) Causes osmotic diuresis that actually washes out the renal tubules forcefully. Frusemide-Use of frusemide (Lasix) 80�120 mg intravenously, two doses at intervals of two hours is advocated. The principles in the administration are: (1) To control the fluid steadiness (2) To keep the caloric requirement (3) To regulate the electrolyte imbalance (4) To give adequate supportive remedy (5) To forestall problems (hyperkalemia, hyperphosphatemia, hypocalcemia, metabolic acidosis). Fluid balance: In the anuric part, water is eradicated via the extrarenal routes, i.

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The neutrophil response is extra rapid and the lifespan of these cells is short spasms after hysterectomy discount nimodipine 30 mg fast delivery, whereas monocytes turn out to be macrophages in the tissues spasms spanish buy nimodipine 30 mg on line, can live for lengthy durations muscle relaxant non prescription generic 30 mg nimodipine with visa, and so the macrophage response may last for a chronic time spasms below left breast purchase 30mg nimodipine. Neutrophils primarily use cytoskeletal rearrangements and enzyme assembly to mount speedy, transient responses, whereas macrophages rely mostly on new gene transcription. A, the light micrograph of a WrightGiemsa�stained blood neutrophil shows the multilobed nucleus, because of which these cells are additionally referred to as polymorphonuclear leukocytes, and the faint cytoplasmic granules. B, the sunshine micrograph of a WrightGiemsa�stained part of pores and skin shows a mast cell (arrow) adjoining to a small blood vessel, identifiable by the purple blood cell within the lumen. The cytoplasmic granules in the mast cell, which are stained purple, are crammed with histamine and different mediators that act on adjoining blood vessels to promote elevated blood circulate and delivery of plasma proteins and leukocytes into the tissue. Note that the two cell sorts share many features, similar to phagocytosis, chemotaxis, and talent to migrate through blood vessels into tissues. Neutrophils are produced within the bone marrow and come up from precursors that also give rise to mononuclear phagocytes. An adult human produces more than 1 � 1011 neutrophils per day, every of which circulates in the blood for a number of hours or days. Neutrophils could migrate to sites of an infection quickly after the entry of microbes. The main function of neutrophils is to phagocytose microbes, especially opsonized microbes, and merchandise of necrotic cells and destroy these in phagolysosomes. In addition, neutrophils produce granule contents and antimicrobial substances that kill extracellular microbes but can also harm healthy tissues. Mononuclear Phagocytes the mononuclear phagocyte system includes circulating cells known as monocytes, which become macrophages after they migrate into tissues, and tissue resident macrophages, which are derived largely from hematopoietic precursors throughout fetal life. Development of Monocytes and Macrophages Macrophages are broadly distributed in all organs and connective tissue. Many tissues are populated with long-lived resident macrophages derived from yolk sac or fetal liver precursors throughout fetal development, they usually assume specialised phenotypes relying on the organ. Examples are Kupffer cells lining the sinusoids within the liver, alveolar macrophages within the lung, and microglial cells in the mind. Subsets of Monocytes Monocytes are 10 to 15 �m in diameter, and so they have bean-shaped nuclei and finely granular cytoplasm containing lysosomes, phagocytic vacuoles, and cytoskeletal filaments. In the steady state in adults and through inflammatory reactions, precursors within the bone marrow give rise to circulating monocytes, which enter peripheral tissues, mature to kind macrophages, and are activated domestically. In early growth, as in fetal life, precursors within the yolk sac and fetal liver give rise to cells that seed tissues to generate specialized tissueresident macrophages. In each people and mice, probably the most quite a few monocytes, referred to as classical or inflammatory monocytes, produce inflammatory mediators, are phagocytic, and are quickly recruited to sites of infection or tissue injury. These cells also are found in the spleen, from where they are often recruited into the circulation in response to systemic inflammatory stimuli. The second type of circulating monocyte, called nonclassical monocytes, are recruited into tissues after an infection or damage and should contribute to restore. Some of these cells are known to crawl alongside endothelial surfaces (described as patrolling). Functions of Macrophages Tissue macrophages perform a number of necessary functions in innate and adaptive immunity. Macrophages typically reply to microbes almost as rapidly as neutrophils do, however macrophages survive for a lot longer at websites of irritation. Therefore macrophages are the dominant effector cells of the later levels in the innate immune response, several days after an infection begins. Macrophage Receptors and Activation Macrophages are activated to carry out their functions by recognizing many different kinds of microbial molecules, as well as host molecules produced in response to infections and harm. These numerous activating molecules bind to particular signaling receptors positioned on the surface of or inside the macrophage. Macrophages are also activated when different plasma membrane receptors bind opsonins on the surface of microbes. Examples of opsonin receptors are complement receptors, which bind fragments of complement proteins connected to microbial surfaces, and immunoglobulin G (IgG) Fc receptors, which bind to one end of IgG antibody molecules that already have microbes bound at the different finish, mentioned in Chapter 13. The clearest instance of that is the response of macrophages to different cytokines made by subsets of T cells. Some of those cytokines activate macrophages to become efficient at killing microbes, referred to as classical activation, and these cells are called M1 macrophages. Other cytokines activate macrophages to promote tissue transforming and restore, called different activation, and these cells are referred to as M2 macrophages. These different pathways of activation and the cytokines concerned are discussed in Chapter 10. Macrophages can also assume totally different morphologic types after activation by exterior stimuli, similar to microbes. Some develop ample cytoplasm and are referred to as epithelioid cells due to their resemblance to epithelial cells of the skin. Activated macrophages can fuse to kind multinucleated giant cells, which happens regularly in sure types of microbial infections, corresponding to with mycobacteria, and in response to indigestible international our bodies. In addition to ingesting microbes, macrophages ingest necrotic host cells, including cells that die in tissues because of the results of poisons, trauma or interrupted blood provide, and neutrophils that die after accumulating at websites of an infection. Macrophages also recognize and engulf apoptotic cells before the useless cells can release their contents and induce inflammatory responses. Throughout the body and throughout the life of a person, undesirable cells die by apoptosis as a half of many physiologic processes, such as development, progress, and renewal of healthy tissues, and the lifeless cells are eradicated by macrophages. Macrophages are activated by microbial substances to secrete a quantity of different cytokines that act on endothelial cells lining blood vessels to improve the recruitment of extra monocytes and other leukocytes from the blood into websites of infections, thereby amplifying the protecting response against the microbes. Other cytokines act on leukocytes and stimulate their migration to tissue sites of an infection or harm. This function is essential in the effector phase of T cell�mediated immune responses (see Chapters 6 and 10). Macrophages promote the repair of broken tissues by stimulating new blood vessel development (angiogenesis) and synthesis of collagen-rich extracellular matrix (fibrosis). These features are mediated by cytokines secreted by the macrophages that act on varied tissue cells. Mast Cells, Basophils, and Eosinophils Mast cells, basophils, and eosinophils are three extra cell varieties that play roles in innate and adaptive immune responses. All three share the common property of 18 Chapter 2 � Cells and Tissues of the Immune System having cytoplasmic granules crammed with varied inflammatory and antimicrobial mediators, which are launched from the cells upon activation. Another widespread characteristic of those cells is their involvement in immune responses that protect in opposition to helminths and reactions that cause allergic ailments. We will introduce the options of these cells in this part and discuss their features in additional element in Chapter 20.

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However muscle relaxant flexeril 10 mg cheap 30mg nimodipine with mastercard, preterm supply may have to infantile spasms 2 month old order nimodipine 30 mg be done in circumstances muscle relaxant pregnancy safe order nimodipine 30 mg without a prescription, similar to: (1) Recurrence of brisk hemorrhage and which is continuing muscle relaxant neck pain order 30mg nimodipine fast delivery. Steroid therapy is indicated when the period of pregnancy is lower than 34 weeks. Betamethasone reduces the chance of respiratory misery of the newborn when preterm supply is taken into account (see p. Active (Definite) Management (Delivery): the indications of definitive management (delivery) are: (1) Bleeding happens at or after 37 weeks of pregnancy. Cesarean delivery is finished for all ladies with sonographic proof of placenta previa the place placental edge is within 2 cm from the inner os. During the current years, there was wider use of cesarean part, in an attempt not only to reduce the maternal danger but in addition to improve the fetal salvage. Vaginal supply may be considered where placenta edge is clearly 2�3 cm away from the internal cervical os (based on sonography). If, amniotomy fails to stop bleeding or fails to provoke labor, cesarean section is performed. Placenta accreta is the attachment of placenta on to the myometrium without any intervening decidua basalis (see p. Important risk components for placenta accreta are: placenta previa and prior cesarean supply. Interventional radiology and uterine artery embolization can management hemorrhage and avoid hysterectomy. In anteriorly located placenta, the placenta has to be cut or separated to deliver the baby. Umbilical wire should be clamped instantly to prevent neonatal hypovolemia and anemia. The edges of uterine minimize margins become so vascular and friable, that the tissues might minimize via during suturing. Classical cesarean part: (A) Advantages: (1) the operation can be accomplished extra quickly. To deal with the engorged vessels on the anterior uterine wall - to put two ligatures and to reduce in between whereas making the transverse incision. To sort out the placenta lying beneath the incision -Incision should be made away from the placental site. Otherwise the placenta may have to be separated manually to get the lower margin and then membranes are ruptured. Alternatively, the placenta could need to be minimize promptly to enter into the amniotic sac to deliver the baby. In both case, the wire is to be clamped rapidly to stop further fetal exsanguination. In fact, fetal blood loss begins from the second the placenta is separated or cut. If hemostasis by sutures fails and the uterus is to be preserved using B-Lynch suture (see p. Isthmic-cervical apposition suture - helps to management bleeding from the lower phase specially in a case with placenta previa or morbid adherent placenta. A suture is handed through the lower flap of the uterine incision (2 cm medial to its lateral border) to the posterior side. The same suture is then introduced again through (1 cm medial to the first) posterior to the anterior uterine wall after which tied anteriorly. It will increase from 1% with no prior scar to 3% with three prior cesarean scar (see p. Incising the placenta for supply causes more hemorrhage and may finish in hysterectomy. Any try of placental separation in a case with morbid adherent placenta (placenta accreta) should be avoided as it excites huge hemorrhage and risks hysterectomy. In presence of bleeding, hysterectomy could possibly be carried out after closing the uterus with none try and separate the placenta. B-Lynch suture, isthmic cervical apposition suture, uterine and inner iliac arteries ligation or intervention radiology and uterine artery embolization (see p. A multidisciplinary staff strategy (urologists, transfusion specialists) ought to be made. The collected blood is prevented from coming out of the cervix by the presenting half which presses on the decrease section. At times, the blood might percolate into the amniotic sac after rupturing the membranes. More and extra circumstances of placental abruption are being diagnosed within the current years. Risk factors are: (a) excessive birth order pregnancies with gravida 5 and above - 3 times more frequent than in first delivery (b) advancing age of the mom (c) poor socio-economic situation (d) malnutrition (e) smoking (vasospasm). Preeclampsia, gestational hypertension and important hypertension, all are associated with placental abruption. The mechanism of the placental separation in preeclampsia is: Spasm of the vessels within the utero-placental bed (decidual spiral artery) anoxic endothelial harm rupture of vessels or extravasation of blood in the decidua basalis (retroplacental hematoma). Trauma: Traumatic separation of the placenta normally leads to its marginal separation with escape of blood outside. The trauma may be as a end result of: (i) Attempted exterior cephalic model specially beneath anesthesia utilizing great drive (ii) Road site visitors accidents or blow on the stomach (iii) Needle puncture at amniocentesis. Sudden uterine decompression: Sudden decompression of the uterus leads to diminished surface space of the uterus adjacent to the placental attachment and ends in separation of the placenta. This could occur following- (a) delivery of the primary baby of twins (b) sudden escape of liquor amnii in hydramnios and (c) untimely rupture of membranes. Short twine, either relative or absolute, can bring about placental separation during labor by mechanical pull. Sick placenta: Poor placentation, evidenced by irregular uterine artery Doppler waveforms is associated with placental abruption. Folic acid deficiency even with out evidence of overt megaloblastic erythropoiesis - this has been observed to be related. Uterine issue: Placenta implanted over a septum (Septate Uterus) or a submucous fibroid. Torsion of the uterus leads to increased venous pressure and rupture of the veins with separation of the placenta. Cocaine abuse is associated with elevated threat of transient hypertension, vasospasm and placental abruption. Prior abruption: Risk of recurrence for a girl with earlier abruption varies between 5% and 17%. The collected blood (decidual hematoma) at the early part, hardly produces any morbid pathological modifications within the uterine wall or on the placenta. However, depending upon the extent of pathology, there may be degeneration and necrosis of the decidua basalis as nicely as the placenta adjacent to it. Rupture of the basal plate may also happen, thus communicating the hematoma with the intervillous space.

References

• Morris RK, Malin GL, Quinlan-Jones E, et al; Percutaneous vesicoamniotic shunting in Lower Urinary Tract Obstruction Collaborative Group: Percutaneous vesicoamniotic shunting versus conservative management for fetal lower urinary tract obstruction (PLUTO): a randomised trial, Lancet 382(9903):1496n1506, 2013.
• Allen R. Dopamine and iron in the pathophysiology of restless legs syndrome (RLS). Sleep Med 2004; 5:385-91.
• Ekeh PA, McCarthy MC, Woods RJ, et al. Complications arising from splenic embolization after blunt splenic trauma. Am J Surg. 2005;189:335-339.
• Jones VS, Cohen RC: An eighteen year follow-up after surgery for congenital microgastriaocase report and review of literature. J Pediatr Surg 42:1957, 2007.