Creating Waves of Awareness
While ausculatating the fetal heart sounds, I really felt a murmur! Hence, the case was referred for Doppler USG and the report came as normal, no cardiac lesions found. Then I had a discussion with the radiologist, who said that the fetal heart murmur can not be auscultated with the ordinary stethoscope. Later the gynecologist also did the USG and said that nothing to worry. Hence the case was not referred for targeted fetal eco cardiography. When the baby was delivered by LSCS, it was diagnosed as Ebstein’s anomaly. As a medical practitioner, my diagnosis was correct, but the painful fact is, it was my own child, who survived only 26 hours.
The lesson for all of us:
1. The second and third opinion is always valid in medicine; even if the findings are normal.
2. Do not ignore even the trivial complaints given by the patients or bystanders. Sometimes, they can even save the doctors from medico legal issues.
3. Fetal heart murmur can be auscultated with an ordinary stethoscope (Using the bell of the stethoscope). I found the sound becomes clearer when we auscultate after applying some cosmetic cream on the skin.
4. USG and Doppler may not always detect congenital heart disease, but very close observation can do the same. When doubtful, better do targeted fetal echocardiography. Unfortunately, it is rarely available.
5. Once we diagnose any fetal anomaly, do LSCS in a hospital having NICU, so that the time for shift to another hospital can be avoided.
6. The lab investigation reports may or may not provide the details about the case, but what is more important is the correlation with the clinical findings and logical thinking of the clinician.
7. We can’t blame people when they go directly to super specialized hospitals even for treating cold and coryza. True that most of them will have to bear unnecessary expenditure, but if the cause for cold and coryza is due to life threatening infection like meningitis, they will get immediate care than others.
8. There must be options to give homeopathy in ICU so that the patients get maximum benefit. There are many situations in which Homeopathy can do wonders, but unfortunately, only a few Homeopathic physicians get this opportunity.
9. Do not ignore the conditions written as “rarest” in the medical textbooks and journals. It may be rarest, but we may be the victim of the same. Even our patients can be affected. The diseases found in one out of one billion populations is also important in medicine as that ‘one’ could be our own child or patient.
10. During pregnancy, avoid the excess intake of food items that may contain lithium, as lithium excess may result in Ebstein’s anomaly.
11. The last message, but the most important one: The decision of the God Almighty is the final; no one can change it.
© Dr Muhammed Rafeeque
Department of Homeopathy
Govt of Kerala.
Lithium is a naturally occurring alkali metal found in numerous foods and drinking water, especially that which comes from river basins and other fresh sources. Most foods contain concentrations of just thousandths of a milligram.
Lithium from water concentrates in crustaceans and mollusks, and to a very small amount in fish. This includes shrimp, lobster, oysters and scallops. Dairy, eggs and meat also contain slight concentrations of the trace mineral.
Pulses, which are legumes and include dry peas and beans, lentils, chickpeas and soybeans, contain some of the highest amounts of lithium available in food. Vegetables, as a general category, contain significantly less lithium than legumes but are still a source. The sea vegetable kelp, blue corn and mustard from fresh mustard seeds also contain trace amounts of lithium.
Grains and Nuts
Grains, particularly wheat and rice products, contain small amounts of lithium. Pasta, as it is usually made with wheat, has small concentrations too. Pistachios are a known source of lithium, as is coffee. Dried fruits and seeds also contain minuscule amounts of lithium.
Ebstein's anomaly is a congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.
Ebstein anomaly is an abnormality in the tricuspid valve. The tricuspid valve separates the right atrium (the chamber that receives blood from the body) from the right ventricle (the chamber that pumps blood to the lungs).
In Ebstein anomaly, two leaflets of the tricuspid valve are displaced downward into the pumping chamber. The third leaflet is elongated and may be tethered to the wall of the chamber. Rarely, the valve is so deformed that it will not allow blood to flow easily in the normal direction (right atrium to right ventricle).
More commonly, these abnormalities cause the tricuspid valve to leak blood backwards into the right atrium when the right ventricle contracts. As a result, the right atrium becomes enlarged. If the tricuspid regurgitation (leak) is severe enough, congestive heart failure can result.
If there is excessive back flow into the right atrium, the pressure within the right atrium becomes very high. Normally, a fetus has a communication or hole between the right atrium and left atrium known as the foramen ovale or PFO. The PFO usually closes after birth.
In Ebstein anomaly, the high pressure in the right atrium keeps the PFO open. This connection allows un-oxygenated ("blue") blood to flow from the right atrium, bypassing the lungs and going directly to the body. This will result in lower oxygen levels in the blood. This is why children with Ebstein anomaly may be blue or "cyanotic," and have low oxygen saturation.
Ebstein anomaly may occur with other heart lesions, such as pulmonary valve stenosis or atresia, atrial septal defect or ventricular septal defect. In addition, many patients with Ebstein anomaly have an accessory (extra) conduction pathway in the heart (Wolff-Parkinson-White syndrome) leading to episodes of abnormal fast heart rate (supraventricular tachycardia.)