How to Overcome Depression Naturally

Spend at least one hour each week with a close friend.

In a British study, when 86 depressed women were paired with a volunteer friend, 65 percent of the women felt better. In fact, regular social contact worked as effectively as antidepressant medication and psychotherapy. Regular social contact with a close friend may boost self-confidence and encourage you to make other positive changes that will help lift depression, such as starting an exercise program. 

Play with a dog a few minutes every day.

When non-pet owners played with a dog for just a few minutes a day as part of a University of Missouri study, blood levels of the brain chemicals serotonin and oxytocin—both mood elevators—rose. You don’t need to own a dog to experience these feel-good effects (although dogs are great antidotes to the kind of chronic stress that can result in depression). Pet your neighbor’s dog for a few minutes a day, volunteer at an animal shelter, or stop by your local pet store for some furry one-on-one therapy

Get a 12-minute massage three times a week.

Whether you pay a professional or ask a spouse or friend to rub your back, the result is the same: a natural mood boost. In a study of depressed dialysis patients, participants who received a 12-minute massage three times a week were less depressed than those who didn’t get the soothing rub. Another study of 84 depressed pregnant women found those who received two 20-minute massages a week from their partners reduced their incidence of depression 70 percent. Researchers suspect massage boosts serotonin levels (which jumped 17 percent in the women who received twice-weekly massages) and reduces levels of the stress hormone cortisol.

Drink one to two cups of coffee or tea each morning.

Regular, modest caffeine intake decreases the risk of depression by more than 50 percent, says Edward J. Cumella, Ph.D., a licensed psychologist and director of research and education for the Remuda Ranch Treatment Centers in Wickenburg, Arizona.

Look for mood-boosting foods.

Walnuts, kiwi, bananas, sour cherries, pineapple, tomatoes, and plums are all naturally high in serotonin. You can also eat foods high in tryptophan, an essential amino acid that your body converts to serotonin, a natural mood booster. Tryptophan is commonly found in proteins such as turkey, fish, chicken, cottage cheese, nuts, cheese, eggs, and beans. Consuming high-carbohydrate foods also encourages the amino acid tryptophan to flood your brain, boosting serotonin levels. A slice of whole wheat bread slathered with honey, a snack of air-popped popcorn: look for whole grains, as white flour will provide similar benefits but its effects wear off quickly.

Get more omega-3s.

A Dutch study found that people who consume diets rich in omega-3 fatty acids, a type of fat found in cold-water fish such as salmon and mackerel, were less likely to suffer from depression than people whose diets were low in this important fat. Another study, this one conducted in England, found that pregnant women who didn't eat fish had twice the rate of depression as women who ate 10 ounces of fish a day. In fact, one reason researchers think the rate of depression has skyrocketed in this country is that we get so few omega-3 fatty acids in our diets. Another good idea for getting your omega-3s: Keep a container of ground flaxseed in the fridge. Flaxseeds, walnuts, soybeans, kidney beans, and black beans are all excellent sources of omega-3 fatty acids.

Take your vitamins.

Ask your doctor if you should take 600 milligrams of chromium picolinate a day; in a study completed at Duke University, people with atypical depression—characterized by mood swings, carbohydrate cravings, weight gain, and lethargy—boosted their mood and reduced their carbohydrate cravings and other symptoms when they began supplementing their diet with chromium. You should also get the recommended amount (400 micrograms) of folate, an important B vitamin that may help lift depression. In a Finnish study published in the Journal of Nutrition, participants with the lowest folate consumption were at the highest risk for depression. Another study, published in the Annals of Clinical Psychiatry, found this vitamin helps enhance the effectiveness of antidepressant medication.

First thing in the morning, lie on your back with your head hanging over the edge of your bed.

Grip a 5- or 10-pound dumbbell with both hands and extend it behind your head, letting your arms hang down toward the floor. Take 10 deep breaths, trying to expand your rib cage as much as possible. Bring the weight back and place it on the bed beside you. Scoot onto the bed so your head is supported, and take another 10 deep breaths. Repeat three times. The stretch will open your rib cage and chest, making it easier to take a deep breath. “The most common unrecognized source of mild depression is restricted trunk flexibility that interferes with full respiration,” says Bob Prichard, a biomechanist and director of Somax Sports in Tiburon, California. “Most people with mild depression are shallow breathers because their chest and stomach are too tight to allow full, easy breathing,” he says.

Look in the mirror and force your lips into a smile.

“Research shows that the physiology of smiling actually makes you feel happy,” Dr. Cumella says. Laughter helps stimulate production of the feel-good hormone serotonin, so if you're feeling down try watching a funny movie or stand up routine.

Pull an all-nighter.

Staying up all night for one night—and therefore depriving yourself of sleep—has been shown to lift depression for as long as a month. Although researchers aren't sure why it works, they speculate that one night of sleep deprivation may reset the sleep clock, enabling people who are depressed to sleep better.

Bang on something.

Employees at a retirement community who took a drumming class felt more energetic and less depressed six weeks after the class than before they started it. Researchers speculate that drumming helps to relax your body. Whacking a few notes out on your desk may help, but joining a weekly drumming circle may help more, particularly since it provides camaraderie with others, which, as noted earlier, also helps with depression.

CASE PRESENTATION ON UTERINE FIBROIDS

A 49 yrs female from Nayapati , presented in Gynaecological OPD
with C/O:

 Abdominal Pain on/off since 2 yrs

 Lumpiness in the lower abdomen  since 1 yr


HISTORY OF PRESENT ILLNESS 

 Mild grade dull intermittent lower abdominal pain  for 2  yrs with no radiation and no aggravating and relieving  factors.

 Lumpiness in lower abdomen for 1 yr, gradually  increasing in size.

 History of intermittent  burning epigastric pain associated with  waterbrash since 1 yr.

 Burning micturition and increased frequency of  micturition since 15 days

 Bowel habit normal

 No history of Per-Vaginal bleeding/discharge/fever

 Sleep/Appetite:­ Normal



PAST HISTORY

No history of similar illness in the past.

No history of still birth,twins,blood transfusion,diabetes mellitus,hypertension,epilepsy.

No history of surgical intervention.


 MENSTRUAL HISTORY

 Menarche(K) = 13 yr .

 Last Menstural Period(L.M.P) = 5th shrawan 2072 .

Flow/Cycle = ­(3­4)/(28+/­4) days .

Average flow, no clots.

 Intermenstural Bleeding =Absent.­

Post-coital bleeding = Absent.­



OBSTETRICAL HISTORY 

 Married for 35 yrs

 PARITY = 3 , LIVE BIRTHS = 3

 Each child was delivered  at home, on achieving full term.

 Last conception , curettage was done 22 yrs back at  8weeks Period Of Gestation (POG),  on patients wish.



 CONTRACEPTIVE HISTORY

 Minilap was done 22 years back.



PERSONAL HISTORY 

Consumes mixed diet.

Non-alcoholic and Non-smoker.


ALLERGIC AND DRUG HISTORY

No history of allergen known till date.

No significant history of drug.


EXAMINATION

ON EXAMINATION

 General Condition :­ Well oriented to time, place and person, average build, supine  decubitus.

 Bilateral pitting pedal oedema (mild) .

 Other Cardinals (Pallor/Icterus/Lymph/Cyanosis/Clubbing/Dehydration) : ­Absent .

 Vitals :­
 
    • Pulse                       : 78 beats per minute
    • Blood Pressure       : 120/80 mm of hg(mercury)
    • Respiration Rate     :  24 breaths per minute
    • Temperature           : 97 degrees Farhenheit (F)

 Chest:­

    • Bilateral Normal Vesicular Breath sounds heard.
 
    • Absence of Added sounds.

Cardiovascular System(CVS) :

     •1st and 2nd heart sounds were heard with an absence of murmurs.
 
     •No deformity detected.


Abdominal Examination :

    •Absence of scar marks/bruits/excoriations.

    •All quadrants moving equally with each inspiration.

    •No local rise of temperature/ Non-tender.


 Per-Abdominal Examination:­

  • Uterus at 16 weeks size.

  • Firm smooth mass, more often felt towards the right side.

  • Upper edge and two lateral boarders smooth, lower  boarders couldn’t be palpated.

  • Non­tender.


 Per-Vaginal Examination :

 • Vulva/Vagina:­ Normal

 • Solid firm mass of 16 wks size felt through right Fornix,  mass mobile and non tender

 • Left Fornix free. Investigations





INVESTIGATIONS


 Cervical cytology:­

 • Normal Smear


 Ultrasonography:­

 • Normal Upper abdominal scan.

 • Bulky uterus with large uterine fibroid.

 • Rounded heterogenously hypoechoic solid  lesion of size 12*11.6*10.5 cm occupying whole of the uterus.



PRE-­OPERATIVE Investigations

 Total Leucocyte Count:­4,600/cu mm

 Differential Count: Neutrophils 63, Lymphocytes 33, Eosinophils 00, Basophils 00

 Blood group:­ A+ve

 Hb:­ 12.8 gm%

 RBS:­ 116mg/dl

 Platelets:­ 205000 /cu mm

 Urine Routine Examination:­ Normal.

 Na:­ 136 Meq/L, K:­ 3.9 Meq/L

 Urea:­ 20mg/dl mCreatinine:­ 1mg/dl

 Chest X­ray:­ There were no abnormality detected.

 ECG:­ Normal Sinus rhythm, nonspecific T­wave changes in lead L3 and  AVF

 Medical Consultation:­ Patient was Advised for ECHO

 ECHO:­

  • Mild TR.

  •Tivial PR and MR.

  • Left Ventricular contraction and  ejection within normal limit


 Anaesthesia consultation:­

 • Patient was fit for surgery.

 •Arrange for 2 Pint of  blood for Operation.


OPERATION

 Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy (done on 2072/04/23)

 Operative finding:­

• Fibroid of 20wks size

• B/L tubes normal

• Left ovary adherent to intestine

• Rt Ovary Normal

• Specimen sent for HPE(Histopathological Examination)

• Blood loss 500ml.

• 1 Pint of whole blood transfused intraoperatively.



Post­Operative Notes:

 2nd pint of blood was transfused in Post-Operative ward on operative day.

 Post Operative Period was uneventful and  patient was discharged on 30th after a week (7th postoperative day).





TEXT REVIEW ON UTERINE FIBROID 

DEFINATION:

Benign tumours which arise from the uterine  myometrium or less commonly from the cervix.

COMPOSITION:
Smooth muscle with variable amount of connective tissue, but of smooth muscle origin. Also called as leiomyomata or myomas.

Aetiology:

 Unclear, each fibroid is derived from smooth muscle cell rest, either from vessel wall or uterine musculature. Fibroid  growth is dependent on ovarian hormones, oestrogen, GH,  HPL.
But points in favour of oestrogen are more suggestive:

• Rarely found before puberty, ceases to grow after  menopause.

• New myomas rarely appear after menopause.

• Association of fibroids in women with  hyperoestrogenism is evidenced by endometrial  hyperplasia, DUB, endometrial Carcinoma.

• Fibroids increase during pregnancy and with OCP.

• Progesterone inhibits the growth of myomas.



EPIDEMIOLOGY:

 It is estimated that around 20% of women of reproductive age have ut. Fibroid.

 Presentation occurs most commonly towards the end  of reproductive life.

 3 fold greater incidence among black where they also  present at younger age.

 May be present in as many as 1 in 5 women above  35yrs.

 Often enlarge during pregnancy or during oral  contraceptive use, and regress after menopause

 Obesity increases the risk of developing fibroids,  cigarette smoking is associated with a reduced risk. ( Ross et al 1986).



ANATOMY:

 Typical fibroid is a well  circumscribed tumour with a  pseudo capsule, firm in  consistency.

 Cut­ surface is pinkish white  with whorled appearance.

 Capsule consists of  connective tissue which fixes  the tumour to the myometrium.

Microscopic Appearance 

Tumour consists of bundles of plain muscle cells, separated by varying  amount of fibrous strands.



Varieties of leiomyoma: 

1.Uterine:
•cervical.
•Corporeal

2.Extrauterine:
•Round lig
•broad lig
•Recto-vag.
•utero - sacral

3.Leiomyomatosis
•tunica Myoma
•extension from Myoma



DISTRIBUTION OF UTERINE FIBROIDS

Uterine leiomyoma:
1.Cervical
•1-2%
•solitary

2.Corporeal
•98%
•multiple

Corporeal leiomyoma:
 1.Submucous
 •15%
 •not capsulated

2.Subserous
•10%

3.Interstitial
•75%



VARIETIES OF UTERINE FIBROIDS

INTRAMURAL (interstitial):

•Symetrically growing tumour remaining within the myometrial wall


SUBSEROUS:

•Grows outside towards the peritoneal surface, shows bossy growth.

•Further extrusion outside with development of pedicel makes it a PEDUNCULATED FIBROID.

•If such tumour gets attached to a vascular organ and is cut of from its uterine origin it is called as    PARASITIC FIBROID.


SUBMUCOUS:

•Uterine contractions may force fibroids toward the cavity, when it is Covered by thin endometrium.

•It may force itself down towards the vagina by a pedicle and become SUBMUCOS FIBROID  POLYP.

DEGENERATIVE CHANGES IN THE FIBROID 

ATROPHY: 

Due to less blood supply after menopause there is shrinkage of tumor which becomes firmer and fibrotic. similar changes after  delivery.

CALCEROUS DEGENERATION:

Phosphates and carbonates of lime are deposited in the periphery along the course of blood vessels. occurs in old patients with long  standing fibroids. “womb­ stones in graveyard” pattern.

RED DEGENERATION:

Occurs mostly during pregnancy, fibroid becomes tense, tender  and causes severe abdominal pain and constitutional upset and  fever.

TORSION:
Subserous pedunculated fibroid may undergo rotation at its site of attachment. This may result into PARASITIC FIBROID.

INVERSION:
An inversion of uterus is caused by a submucous fundal myoma.

CAPSULAR HEMORRHAGE: If one of large veins in surface of Subserous myoma ruptures, profuse  intraperitoneal haemorrhage can cause acute hemorrhagic shock.

INFECTION: Is common in Submucous and myomatous polyp if it projects into cervical canal or into the vagina.

OTHER COMPLICATIONS

SARCOMATOUS CHANGES:

                                                                 Sarcomatous change

Extremely rare, no more than 0.5%, intramural and Submucous tumours have more potential than Subserous.



PREGNANCY COMPLICATION:

While many pregnancy associated with fibroids proceed uneventfully, there is increased risk of spontaneous abortion and preterm labour.

ASSOCIATED ENDOMETRIAL CARCINOMA:

Is associated with fibroid in women over 40 yrs in 3%.



DIAGNOSIS

History

Examination.

Investigation.

Differential Diagnosis.

 Patients may have a single symptom or present with several symptoms depending upon no, size and location though 50%  are asymptomatic.




                                                        SYMPTOMS

MENSTRUAL DISORDERS:­ 

Progressive menorrhagia:­ Seen in intramural and Submucous.

Polymenorrhoea:­Occurs when cystic ovaries and PID coexist Metrorrhagia:­In submucus fibroid.

INFERTILITY:­ 

 Due to associated PID , endometriosis . distortion of uterine cavities   causing obstruction to sperm ascent, Poor nidation , corneal tubal  block.

 Submucus myoma is responsible for recurrent pregnancy loss.

 PAIN:

 Most fibroids are painless

 Most complain of heaviness in lower abdomen. Congestion and spasmodic  dysmenorrhoea is often due to associated PID.

 Acute pain suggests torsion, haemorrhage and red degeneration.

PRESSURE SYMPTOMS:­ 

 Anterior and posterior fibroid lodged in pouch of Douglas cause frequency and  retention of urine.

 Broad ligament fibroid causes hydroureter and hydronephrosis.Very rarely  intestinal obstruction due to loop of intestine around pedunculated fibroid.

ABDOMINAL LUMP:
  
 large fibroid may be obscured as an abdominal tumor which grows slowly or not  at all over a long period.

OTHER SYMPTOMS:­ 

 Anaemia  causing DYSPNOEA AND PALPITATION.

 Ascitis if pseudomeigs syndrome is associated.

 Haemorrhagic shock if intraperitoneal haemorrhage




                                                        PHYSICAL SIGNS

ANAEMIA Of various degrees.

ABDOMINAL LUMP:

 Well defined margin

 Firm consistency

 Smooth and bossy surface

 Mobile side to side unless fixed by large size or adhesions


BIMANUAL EXAMINATION:

 Enlarged uterus,regular or bossy depending upon no., and size of tumor.

 Cervix moves with swelling .swelling not felt separate from uterus unless pedunculated.

 Cervical fibroid:-Normal uterus perched on top of fibroid.

 Myomatous polyp:-Cervical os is open and it’s lower pole is felt.




Differential diagnosis 

 Pregnancy

 Hematometra

 Adenomyosis

 Bicornuate uterus

 Endometriosis

 Ectopic pregnancy

 Chr. Inversion of uterus

 Chronic PID

 Malignant ovarian  tumor

 Benign ovarian     tumor

 Endometrial Ca

 Myomatous polyp

 Pelvic kidney




INVESTIGATIONS:­ 

 Hb%, Blood grouping

 USG

 Hysterosalpingography

 Hysteroscopy

 Dilatation and curettage (D/C)

 Laparoscopy

 X­ray

 CT Scan

 MRI

 IVP





ULTRASONOGRAPHY

 USG is helpful to assess the adnexa if these cannot be palpated separately with confidence.

                                                              Hysterosalphingogram

                                                 • Plain x­ray showing calcified fibroid




Diagonostic hysteroscopy

 Number
 Size
 Site in relation to the tubal ostia and the uterine walls
 Pedicle
 Depth of the myoma in relation to the uterine wall.

MANAGEMENT

 Small and asymptomatic fibroids require no removal , can be observed for 6 months.

 Treatment of women with uterine leiomyomas must be individualized, based on:
1. Symptoms,
2. Size and
3. Rate of growth of the uterus, and
4. The woman’s desire for fertility.



INDICATIONS OF TREATMENT

 Habitual abortion
 Infertility
 Fibroid causing menorrhagia and pressure symptoms.
 Asymptomatic fibroid causing pressure on ureter.
 Rapid growth of fibroma in menopausal women
 When nature of tumor can’t be ascertained clinically.

MODE OF TREATMENT :
•MEDICAL
•MINIMAL INVASIVE SURGERY
•SURGERY



MEDICAL TREATMENT:

1.Gonadotropin-releasing hormone (GnRH) agonists.
 •Fibroids may be expected to shrink by up to 50% of their initial volume within 3 months of therapy.
 • GnRH agonist treatment should be restricted to a 3- to 6-month interval, following which regrowth  of fibroids usually occurs within 12 weeks.
 • GnRH agonists are indicated preoperatively to shrink fibroids and to reduce menstrual related  anemia

2.Tranexamic acid
 May reduce menorrhagia associated with fibroids.

3.Danazol
 Has been associated with a reduction in volume of the fibroid in the order of 20% to 25%.
Although the long-term response to danazol is poor, it may offer an advantage in reducing menorrhagia.

4.Iron therapy
Blood transfusion may be required preoperatively.

5.Mifepristone
50mg daily for 3 months.

SURGERY:

Myomectomy                                             
•Vaginal Myomectomy
•Abdominal Myomectomy
•Hysteroscopic Myomectomy
•Laparoscopic myomectomy

Hysterectomy
•Total Abdominal Hysterectomy
•Subtotal Hysterectomy
•Vaginal hysterectomy
•Laparoscopic Hysterectomy




                                                         HYSTERECTOMY

 The only indications for hysterectomy in a woman with completely asymptomatic fibroids are:

      1. Rapidly enlarging fibroids or,

      2. When enlarging fibroids raise concerns of leiomyosarcoma (after menopause).

 Hysterectomy need not be recommended as a prophylaxis against increased operative morbidity associated with future growth.

 In women who have completed childbearing, hysterectomy is indicated as a permanent solution for leiomyomas causing substantial bleeding,

 When considering pelvic pressure, or anemia hysterectomy for menorrhagia attributed to fibroids, other causes should be ruled out.

 Endometrial biopsy should be considered, to exclude endometrial lesions. Myomectomy
         




MYOMECTOMY THROUGH A LAPAROTOMY INCISION
                     
                         1. Higher risk of blood loss and
         
                         2. Greater operative time with myomectomy than with hysterectomy

 The risk of ureteric injury may be decreased with myomectomy.

 There is a 15% recurrence rate for fibroids and

 10% of women undergoing a myomectomy will eventually require hysterectomy within 5 to 10 years.

 Laparotomy is mostly indicated for:
1. Fibroids exceeding 5 cm to 8 cm,
2. Multiple myomas, or
3. When deep intramural leiomyomas are present.


LAPAROSCOPIC MYOMECTOMY

 For several pelvic disorders, gynaecologists have resorted to minimal access surgery in an effort to:
1. Reduce hospital stay and
2. Improve recovery time.
 • Myomas may be removed by a laparoscopic approach.

 The challenges of this surgery rest with the surgeon’s ability to
1. Remove the mass through a small abdominal incision and
2. Reconstruct the uterus.

 Uterine rupture during a subsequent pregnancy has been reported.

 The risk of recurrent myomas may be higher after a laparoscopic approach, with a 33% recurrence risk at 27 months.

HYSTEROSCOPIC MYOMECTOMY

 Is feasible and very effective, and it should be considered in women with
 Symptomatic intracavitary or Submucous narrow-based intrauterine myomas.
 Indications include :
 • Infertility,
 • Repeated pregnancy losses, and
 • Abnormal uterine bleeding.

  If fertility is not desired and abnormal uterine bleeding is the main symptom, concomitant  endometrial ablation or resection may provide better resolution of abnormal bleeding than  myomectomy alone.

 Recently, Electrosurgical loop electrodes using bipolar technology, as well as Vaporizing electrodes using both monopolar and bipolar technology, have been described as new technologies to facilitate hysteroscopic myomectomy.

HYSTEROSCOPIC MYOMECTOMY

                                                    HYSTEROSCOPIC MYOMECTOMY


UTERINE FIBFOID EMBOLISATION

 Uterine fibroid embolisation (UFE) is a treatment that cuts off the blood supply to the uterus and the  fibroids so they shrink. UFE is proving to be an  alternative to hysterectomy and myomectomy. The  recovery time is also shorter, and there is a much  lower risk of needing a blood transfusion than for  these surgeries. Many women can have UFE and  go home the same day.

THE LATEST IN UTERINE FIBROIDS TREATMENT

MR-Guided Focused Ultrasound Ablation Using ExAblate:

 Is noninvasive;

 Is an outpatient procedure;

 Requires little recovery time;

 Does not require constant medication;

 Has none of the side effects involved in hormone therapy; and

 Does not expose the patient to radiation.

 Uterine fibroid tumors are destroyed through the power of ultrasound energy.

                    MR-guided focused ultrasound ablation (MRgFUS) using ExAblate technology

Family planning: 

For young women with fibroids seeking contraceptive  advice , do not give :

a) Oestrogen containing hormonal contraceptives.

b) IUCD
              barrier method is suitable for such patients.
             

                                                                       THANK YOU!.

HIV IN PREGNANCY

ABSTRACT

After the 25 years since the first case of HIV/AIDS was recorded in the country, the rate of infection seems to be decreasing. 

National HIV/AIDS Strategy (2010-2016) aims to decrease HIV prevalence rate by 50 percent, AIDS related deaths by 25 percent and HIV prevalence in newborns by 90 percent, compared to the situation in 2010. 

According to latest data compiled by the National Center for AIDS and STD Control (NCASC), 1,088 new HIV cases have been reported in 2012. Altogether 1,437 cases were reported in 2011, down from 1,751 cases in 2010. Only 2,433 HIV patients have been receiving the medication provided by the government at present. It is estimated that there are 48,600 people living with HIV/AIDS virus. But, only 21,551 patients have been registered with the government. 

In 2007 : Total no. of patient infected with HIV in Nepal is estimated to be 69790 with 92% in the age group 15–49 yrs

HIV in general population < 1%

Sex ratio: 3:1 (male to female)

In 2007: 1811 women were in need of antiretroviral therapy to prevent mother to child transmission Mother to child transmission is largest source of HIV infection in children in Nepal

Out of estimated 900,000 annual pregnancy, 1800 are estimated to occur in HIV positive women (2005)

WHO estimates at least 50% of people infected with HIV are female. Majority of these women in reproductive years and elect to have children after HIV infection.

2 million HIV infected women become pregnant each year 2000 new HIV infected infants each day.



Epidemiology

Caused by RNA virus characterized by enzyme reverse transcriptase.

Allows viral RNA to be transcribed to viral DNA which is randomly incorporated into host nucleic DNA and subsequently transcribed to produce viral RNA Envelop glycoproteins confer ability for virus to attach to cells bearing CD4+ antigen (esp T- Helper lymphocytes).

Rapid and continous replication of HIV impairs and eventually depletes the patient CD4+ T cell population ----- debilitation of host immune system.

Patient susceptible to opportunistic infections and neoplasia that characterises AIDS.

During replication , mutation occur in DNA copies --- drug resistance.

Initial HIV infection may be asymptomatic.

May produce an acute glandular fever type illness associated with characteristic rash.

Antibodies detected in the serum within 3 months of infection(seroconversion).

Mean time from infection to development of AIDS is 8-10 yrs.

HIV 1: North, Central and South America, Europe and Asia.

HIV 2: West Africa.


Infection is from:

 Blood, semen , saliva, female genital tract secretion and breast milk.



Route of transmission

Sexual intercourse.

Intravenous drug use and use of infected blood and blood products.

Vertical transmission.



HIV in pregnancy

Pregnancy does not accelerate HIV disease progression HIV disease may affect the outcome of pregnancy

IUGR

Preterm birth

Low birth weight

Perinatal and neonatal death

     Does not increase the incidence of congenital anomaly.



Screening of HIV in pregnancy

WHO recommends screening when for any condition, benefits of a positive test outweigh the risks.



Early recognition of HIV disease important in pregnancy

Woman will receive optimal medical care for her condition and various strategi es can be employed to minimise risk of HIV transmission to fetus.

Woman counselled about implications of pregnancy with HIV.

           Option of pregnancy termination where appropriate.

 Pediatrician involved early in the management should woman elect to continue pregnancy.



Types of screening

Universal screening : where seroprevalence is greater.
High risk screening: low prevalence rate.
Opt in method
Opt out method

Mother to child transmission : Issue about HIV infection.

 Voluntary testing and counselling of HIV was first started in Nepal in 1995 at National Center for AIDS and STD control.

 Comprehensive PMTCT service started in Nepal from Feb 2005 at 7 different sites.
 Now there are 17 PMTCT sites in Nepal.
 In Kathmandu: TUTH and maternity hospital.



Mother to child transmission : Issue about HIV infection

Vertical transmission rate: 14% in western world.

Higher transmission rate in developing world.

Breast feeding further increase the risk by 14%.

 Management of pregnancy with HIV made difficult by fact that no practical method of prenatal diagnosis to predict which infants are affected.


Reasons :

Methods of prenatal diagnosis as cordocentesis are invasive and carry risk of infecting fetus with HIV by innoculating maternal blood.

Majority of neonatal infection occurs during delivery process so impossible to predict which neonate will be ultimately infected.
Early diagnosis of HIV infection in neonate difficult as maternal HIV IgG Ab cross the placenta and persist in fetal circulation for upto 18 months.




HIV may be transmitted to infant

During pregnancy

At the time of delivery

Through breastfeeding



Factors increasing risk of transmission:

 HIV seroconversion during pregnancy

High maternal viral load > 5-10,000 copies/ml

Advancing maternal disease(p24 antigenemia)

Malaria

Recurrent STI

Premature delivery

Rupture of membrane more than 4 hours

Vaginal delivery

Invasive procedures during delivery ( vacuum, forceps, episiotomy. Fetal scalp vein sampling)

Placental distruption

Breast feeding



  Care of pregnant women infected with HIV should be Multidisciplinary

Should involve

Obstetrician

HIV physician

General practioner

Pediatrician

Midwives

Health visitors

Social worker 



1. Counseling about implications of pregnancy with HIV disease and provide psycological support

Personal prognosis

Illicit drug use

Vertical transmission rates

No method of prenatal diagnosis

Option of pregnancy termination

Breastfeeding

2. Routine antenatal care

3. Diagnosis and aggressive treatment of malaria, STI and other infection.

4. Educate about MTCT and infant feeding option 

5.Screening and follow up tests in pregnancy


Test                                                                                      Frequency

Complete blood count                                                          3 monthly

Liver function test                                                                3 monthly

Hepatitis B and C markers                                                   baseline

Toxoplasma serology                                                           baseline

Syphilis serology                                                                  baseline

Cervical cytology                                                                 baseline/yearly

T cells                                                                                   3 monthly

P24 antigen                                                                           3 monthly


6. Invasive pre-natal diagnostic procedures should be avoided 


7. At each routine ANC visit,

Require about symptoms suggestive of HIV related infection.

Full physical examination including fundoscopy and chest auscultation performed at minimum of 3 monthly interval by HIV physician.

8. Prophylaxis against Pneumocystic pneumonia indicated if CD4 lymphocyte count falls below 200/mm3 or in women with symptomatic disease.
Cotrimoxazole 960mg/day offers protection also against toxoplasmosis.



Conduct of labor and delivery

Precautions taken to minimise the risk of nosocomial infections to healthcare workers and the risk of vertical transmission to fetus

 Double gloving

Use of water proof gowns

Wearing of spectacles


To decrease vertical transmission

Women of unknown status in labor, offer opt out testing

If not on antiretroviral therapy, give nevirapine

Avoid ARM or leave this as late as possible thereby minimizing fetal contact with maternal secretion

Do only minimal digital examination after rupture of membrane

Chorioamnionitis increase rate of vertical transmission so avoid ascending infection

Reduce use of assisted vaginal delivery

Reduce use of episiotomy

Role of elective LSCS (Lower Segment Caeserian Section)

LSCS if indicated performed by most experienced person available to reduce risk of injury to staff

Third stage conducted actively to reduce blood loss


Neonatal period

Baby should be examined by pediatrician.

Avoid mechanical nasal suction.

Clean the newborn immediately of all maternal secretion and blood.

Hematological, virological and immunological investigations should be undertaken at birth, 6 weeks and 3 monthly thereafter.

Antiretroviral therapy for infants.

Support safer infant feeding.
If breastfeeding chosen: exclusive breastfeeding,
                                advise early and rapid weaning.


 Serological and Virological tests in newborn at risk of HIV

Full blood count and differential count

T lymphocyte subset

Hepatitis B serology

HIV serology– ELISA

Virus isolation by lymphocyte culture.

PCP occur frequently in infants under 6 months so Prophylaxis with co-trimoxazole from 3 weeks of age is Recommended.

Follow up schedule discussed with parents.

Mother will require advice on immunisation.


Vaccine                                                                   Indication

Polio                                                                   Use killed vaccine

BCG                                  Withhold from children definitely known to be infected but give all others

H. Influenza                                                  All HIV infected children

Pneumococcus                                              All HIV infected children

Hepatitis B IG                                                         Within 7 days

Hepatitis B vaccine                                                 1 and 6 months

Support safer infant feeding.

If breastfeeding is chosen: Exclusive breastfeeding Rapid and early weaning.

Counselling on risks and benefit of breast feeding.



 Risk of breastfeeding in HIV infected mothers


HIV infection

Infection risk persists for length of breastfeeding

 Children who receive mixed feeding are at increased risk of HIV infection than children who receive exclusive breastfeeding or exclusive replacement feeding

Shortening the period of breastfeeding may reduce the risk of HIV transmission.

The alternative of exclusively giving replacement feeding also has considerable risks

Studies show that replacement fed babies are 2.5 to 5 times more likely to die from any cause than breast fed babies.



Benefits of breastfeeding in HIV infected mothers 


The immunological, nutritional, psychosocial, and child-spacing benefits are well recognized.

Breast milk plays an important role in preventing the infections that accelerate progression of HIV-related diseases in already infected children.



Nepal PMTCT guidelines on breastfeeding 


When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoid all breastfeeding in women who are HIV positive.

Otherwise exclusive breastfeeding for 6 months.

Avoid mix feeding as formula feed increase G.I. tract inflammation and allows virus to enter infant blood stream easily.

As soon as feasible, discontinue breastfeeding.

Counselling on pros and cons of breastfeeding.



Antiretroviral therapy (ART)

Drugs used to treat HIV infection impair viral replication so delay immunodeficiency and progression to AIDS .Drugs used in pregnancy :

Zidovudine

Nevirapine

ART in pregnancy aims to prevent vertical transmission and maintain maternal health.


Risks : 

Feto-maternal exposure with potential adverse effects.

Emergence of resistent viral strain.

Recommended optimal time to initiate therapy in late 3rd Trimester since less than 2% of mother to infant transmission occur before 3rd trimester.

Role of single agent (monotherapy).



Zidovudine 

100mg orally five times per day from 34 weeks antenatally

2mg/kg body weight i/v for one hour in labor followed by 1mg/kg/hour until delivery

2mg/kg orally every 6 hours for 6 weeks for neonate beginning 8-12 hours after birth

Rate of vertical transmission is reduced by 67% (placebo 25.5% vs AZT 8.3%)


Nevirapine

Nevirapine another single agent used.

200mg Nevirapine at onset of labor.

Single dose 2mg/kg Nevirapine for neonate within 3 days of Delivery.

Relatively cheap, easy to administer and used in developing countries.

Reduce the risk of transmission by 47%.



Pitfall of single dose Nevirapine course


Concerns of resistance with single dose NVP and the future effect on maternal ART efficacy are currently being addressed in trials.

WHO recommendations:

continue with sd NVP prophylaxis programs for now because of potential for huge number of infant infections avoided

await trial results



Combination therapy 


Triple therapy indicated for pregnant women with :

Advanced HIV disease.

High viral load.

Low CD4+ counts.

Since risk of MTCT correlates with these parameters.



Nepal PMTCT (Prevention of mother to child transmission) ARV prophylaxis

Intrapartum short course: Nevirapine 200mg orally at labor onset

Postpartum infant: Nevirapine 2mg/kg oral suspension immediately after birth.


In case mother received no ARV prophylaxis:

•Postpartum infant: Nevirapine 2mg/kg immediately after birth and Zidovudine 4mg/kg twice daily for 7 days.

•If Zidovudine not available : give immediate NVP dose and 2nd dose 72 hours after birth.

The Cholesterol Factor

Cholesterol is a waxy substance that is present in our blood. It's an important component of our cell walls and other tissues, but is thought to be harmful in excess. It can lead to blockages caused by plaque formation in the heart's arteries, causing heart disease and heart attacks. Such blockages can also happen in arteries in the legs, or in the brain. 

Cholesterol is produced in the liver, and the amount produced is influenced by our genes. The food we consume, too, has an effect on cholesterol levels. Fatty foods, especially those high in saturated fats, and foods high in simple sugars such as cold drinks increase cholesterol levels. Lack of physical activity and exercise also lead to elevated levels.
We can reduce or control cholesterol levels by following a heart-healthy lifestyle, which must include regular physical activity-at least 30 minutes daily-and a diet high in fruits and vegetables and low in saturated fat.
Statins are the group of drugs most recommended for those with high cholesterol. For your doctor to 
decide when you should start taking them will depend on your overall clinical picture, not just your cholesterol levels. In general, if you are diagnosed with heart disease and diabetes, you may need to take them. Also, if a test shows your LDL (low density lipoprotein) cholesterol-the "bad" one-to be over 190, you are likely to be prescribed statins. Anyway, the doctor will decide meds on a case-to-case basis.
Red yeast rice (rice that has been fermented by the red yeast, Monascus purpureus) has been shown to be effective in lowering cholesterol. Include garlic and flaxseed in your daily diet. Olive oil, canola oil or other oils rich in monounsaturated fatty acids can be used for cooking in order to reduce cholesterol through food. 

You may not be eating right, so it pays to have your diet evaluated by a nutritionist to ascertain the quantity and frequency of cholesterol rich-foods you may be consuming. These can be suitably substituted with low-fat and zero-cholesterol food options along with foods rich in fibre, to 

reduce your bad cholesterol levels.
A combination of diet, exercise and lifestyle modifications work best in producing long-lasting effects. For the obese, weight reduction is key. Some foods that help manage cholesterol levels well and must be included in your diet are:

• Oats: A suitable breakfast option. The beta glucans present in oats help reduce LDL cholesterol levels.

• Nuts: Walnuts and almonds can be a healthful snack option. They are calorie-dense and you just need to take a few, working them into your meal plan.

• Kidney beans (rajma): Half a cup provides a day's fibre requirement.It can help maintain slower rate of absorption of cholesterol from other foods.

• Green leafy vegetables: Also rich in fibre, they fight arterial plaque formation.

• Avocados: Rich in monounsaturated fat, they work by reducing LDL and upping HDL. But it's high-calorie, so eat in moderation. 

• Black grapes: Both reduce and regulate cholesterol levels. Phytochemicals present are known to be heart protective. 

• Green tea: Drinking green tea improves the functioning of endothelial cells, thereby reducing the risk of clogged arteries. It also helps lower LDL cholesterol levels.

• Flaxseed: Ground flaxseed is digested more easily. Add a tablespoon of ground flaxseed to salads, raita or veggies.

• Wheatgrass: Rich in antioxidants, which are heart friendly, wheatgrass also boosts immune response and detoxifies the body.

• Garlic: Known for its cholesterol-lowering effect when consumed raw or substituted with garlic supplements. Warning: patients on blood thinners such as Warfarin need to check with their doctors about garlic consumption.

• Fish: It is a good source of omega-3 fatty acids, which are heart friendly. Eating up to 150 grams two to three times a week is beneficial. But it should not be fried-fish.

Minimize common cholesterol-rich foods, such as red meat, egg yolk, butter, cheese, ghee, cream, full cream milk and margarine and avoid junk, fast and fried foods. 

Beating Belly Bloat Naturally

1. Cut back on salt

Reduce the amount of salt you are eating to reduce water retention and bloating. Watch for hidden sources of sodium. “Over 80 percent of our daily sodium intake does not come from the salt shaker, but rather from processed and packaged foods.” 

2. Drink more water

Make sure you are drinking enough water. Water will help your body eliminate “extra” salt through your urine. Less salt in your body will help stop swelling and bloating. Go for eight 8-ounce glasses a day.

3. Try a homemade remedy

Stir a teaspoon of baking soda into a glass of water and drink it. This solution neutralizes stomach acid and helps relieve gas and bloating. Add a few drops of lemon to dispel some of the gas before it hits your stomach.

4. Eat less and more often

Eat smaller meals more frequently, perhaps five times a day. Sit down and relax at each meal. Eating your meal slowly will help you avoid stomach bloating and pressure.

5. Cook with anise

In ancient Rome, at the end of an indulgent feast, people would serve cakes made with anise to calm digestion and freshen the breath. Anise is an aromatic digestive, a group of remedies that calms digestive problems, and reduces nausea, gas and bloating.

Anise works well in vegetable soups: add seeds or whole star anise when sautéing onion and garlic. You can also make a tea by pouring boiling water over slightly crushed seeds. Drink a cup of this after dinner, or anytime you are feeling a bloated or gassy.

6. Drink more peppermint tea

Drinking peppermint tea to relieve the symptoms of abdominal gas and bloating. It’s also good for nausea (without vomiting) and for heating up the body and making it sweat.

Peppermint tea can also be made using fresh herbs from the garden—and it’s one of the easiest herbs to grow.

7. Control irritable bowel syndrome

Bloating is characteristic of irritable bowel syndrome (IBS) along with, constipation, diarrhea, and abdominal pain. Keep your IBS under control to reduce belly discomfort. To control these symptoms, doctors recommend staying away from dairy and fatty foods while including a high intake of fiber in your diet.