Pregnancy - physiology


  • hCG - human chorionic gonadotropin - present in blood and urine, produced by blastocyst and placenta
  • Low levels of hCG could mean miscarriage, ectopic pregnancy, miscalculation of dates
  • High levels = molar pregnancy (cells that normally form a baby dysfunction and form cysts instead), multiple pregnancy (twins etc), miscalculation of dates
  • Progesterone increases fat deposition in early weeks and stimulates appetite
  • Increased oestrogen from corpus luteum promotes mammary gland development (breasts enlarge)
  • And inhibits ovulation via negative feedback [OES decreases GnRH release by hypothalamus –> linhibition of FHS and LH –> no ovulation]
  • Relaxin (secreted by corpus luteum) softens connective tissue in preparation for labour - not specific, all joints can be affected
  • Peaks in early and late pregnancy

Physical changes

Blood pressure

  • As early as 4 weeks into pregnancy 
  • plasma volume increase
  • caused by the affects of oestrogen and progesterone on the kidneys

OES and Prg cause vasodilation 

  • less resistance = less pressure
  • Heart rate increases by 25% to compensate
  • stroke volume increases 
  • increased overall cardiac output by 50% in third trimester

Direct action of enlarged uterus:

  • compresses the descending aorta and inferior vena cava 
  • decreased venous return - less blood in means less blood out, less blood in ventricle –> reduced pressure on walls –> reduced force to exit –> reduced placental perfusion
  • increased aortic pressure
  • increased heart rate
  • [shouldn’t sleep on back for this reason]


  • Fall in blood pressure (can cause collapse if serious)
  • Can cause foetal hypoxia even without mother symptoms

Haematological changes

  • red cell mass increase by 20% (renal - increased erythropoietin production in response to detection of blood oxygenation and sodium/water balance)
  • Plasma volume increases more than RBC count does, causing the impression of decreased haemoglobin (anaemia)
  • Increased tendency to clot (hypercoagulable)
  • due to increase in clotting factors and plasma fibrinogen
  • platelet production increase (however count drops due to increase in activity and consumption) - function remains normal]
  • WBC count may increase due to an increase in granulocytes

Respiratory changes

  • Increased chest diameter, diaphragmatic expression and elevation
  • dyspnoea common (difficulty breathing)
  • breathing becomes more costal (mouth) than abdominal 
  • mainly mediated by progesterone levels (cause bronchial and smooth muscle relaxation and hypersensitivity to CO2)

Changes to the urinary system

  • cardiac output increase –> increase in renal plasma flow and glomerular filtration
  • increase in urea, creatinine, urate and biocarbonate clearance 
  • with progesterone, renin and aldosterone up water retention increases
  • can lead to urinary stasis and increased risk of UTI
  • Any drugs given that are excreted renally must be given in much higher quantities consequently

Gastrointestinal changes

  • Appetite increase + cravings 
  • Gastric reflux sphincter relaxation (increased indigestion, also due to increased intra-gastric pressure (expanding uterus)) 
  • gallbladder dilated 
  • GI motility decreased and transit time slower 
  • albumin and protein decrease 
  • cholesterol twice normal value


  • Calcium reuptake into bloodstream results in mild decalcification of bones 
  • relaxin softens joints (pubic symphysis + alters gait (waddling))
  • abdominal muscles stretch to elastic limit 
  • stretch marks (stria gravidarum) caused by rupture of elastic fibres and small blood vessels 

Reproductive changes

  • Massive increase in mass
  • Placenta growth (nutrition, excretion, immunity, endocrine) 

Parental blood supply 


Also, REMEMBER!!!!

* Sulfonamides compete for albumin with:

  • Bilirrubin: given in 2°,3°T, high risk or indirect hyperBb and kernicterus in premies
  • Warfarin: increases toxicity: bleeding

Beta-lactamase (penicinillase) Suceptible:

  • Natural Penicillins (G, V, F, K)
  • Aminopenicillins (Amoxicillin, Ampicillin)
  • Antipseudomonal Penicillins (Ticarcillin, Piperacillin)

Beta-lactamase (penicinillase) Resistant:

  • Oxacillin, Nafcillin, Dicloxacillin
  • 3°G, 4°G Cephalosporins
  • Carbapenems 
  • Monobactams
  • Beta-lactamase inhibitors

* Penicillins enhanced with:

  • Clavulanic acid & Sulbactam (both are suicide inhibitors, they inhibit beta-lactamase)
  • Aminoglycosides (against enterococcus and psedomonas)

Aminoglycosides enhanced with Aztreonam

* Penicillins: renal clearance EXCEPT Oxacillin & Nafcillin (bile)

* Cephalosporines: renal clearance EXCEPT Cefoperazone & Cefrtriaxone (bile)

* Both inhibited by Probenecid during tubular secretion.

* 2°G Cephalosporines: none cross BBB except Cefuroxime

* 3°G Cephalosporines: all cross BBB except Cefoperazone bc is highly highly lipid soluble, so is protein bound in plasma, therefore it doesn’t cross BBB.

* Cephalosporines are "LAME“ bc they  do not cover this organisms 

  • L  isteria monocytogenes
  • A  typicals (Mycoplasma, Chlamydia)
  • RSA (except Ceftaroline, 5°G)
  •  nterococci

* Disulfiram-like effect: Cefotetan Cefoperazone (mnemonic)

* Cefoperanzone: all the exceptions!!!

  • All 3°G cephalosporins cross the BBB except Cefoperazone.
  • All cephalosporins are renal cleared, except Cefoperazone.
  • Disulfiram-like effect

* Against Pseudomonas:

  • 3°G Cef taz idime (taz taz taz taz)
  • 4°G Cefepime, Cefpirome (not available in the USA)
  • Antipseudomonal penicillins
  • Aminoglycosides (synergy with beta-lactams)
  • Aztreonam (pseudomonal sepsis)

* Covers MRSA: Ceftaroline (rhymes w/ Caroline, Caroline the 5°G Ceph), Vancomycin, Daptomycin, Linezolid, Tigecycline.

Covers VRSA: Linezolid, Dalfopristin/Quinupristin

* Aminoglycosides: decrease release of ACh in synapse and act as a Neuromuscular blocker, this is why it enhances effects of muscle relaxants.

* DEMECLOCYCLINE: tetracycline that’s not used as an AB, it is used as tx of SIADH to cause Nephrogenic Diabetes Insipidus (inhibits the V2 receptor in collecting ducts)

* Phototoxicity: Q ue S T  ion?

  • uinolones
  • Sulfonamides
  • T etracyclines

* p450 inhibitors: Cloramphenicol, Macrolides (except Azithromycin), Sulfonamides

* Macrolides SE: Motilin stimulation, QT prolongation, reversible deafness, eosinophilia, cholestatic hepatitis

Bactericidal: beta-lactams (penicillins, cephalosporins, monobactams, carbapenems), aminoglycosides, fluorquinolones, metronidazole.

* Baceriostatic: tetracyclins, streptogramins, chloramphenicol, lincosamides, oxazolidonones, macrolides, sulfonamides, DHFR inhibitors.

Pseudomembranous colitis: Ampicillin, Amoxicillin, Clindamycin, Lincomycin.

QT prolongation: macrolides, sometimes fluoroquinolones



<br /><i>Via Flickr:</i>
<br />As most of you know, it's hard to get these girls out of the studio, and into the woods for a nice photo session.  And usually, when a photographer does get them out on the beaten trail, he ends up zooming in on them anyway.

Note the ‘rickshaw guys (or yama-kago guys) blending into the trees like a couple of bugs on the bark. It must have been a nice crisp, day for photography. I can almost smell the forest.

Here’s the full 3-D version :

This photo is a ca.1900 albumen half-stereoview by an unknown photographer working for the New Hampshire, USA photographer and publisher, Ben Kilburn. Old Ben never made it to Japan, but the guy he sent out did a fine job, and is responsible for a fine group of views published by Kilburn in 1901. This view is “different” because the photographer was well known for tight, closely cropped portraits and groups.

All of Kilburn’s JAPAN , KOREA, and CHINA views were by this same photographer.

Here are some more by the same photographer. For some reason, although I have more JAPAN views than KOREA views by this guy, I have posed more of the Korean ones. Still, there’s a few nice Japan in the group.…

kaveri selitti et se näki unta jossa se oli sauli niinistön kansliassa (joka oli kerrostalossa) ja siellä oli abstrakti teräsbetonin laulaja joka pysty tekeen ukkosta taputtamalla käsiään yhteen ja käytti voimaansa poliittisena protestina ja sale oli tosi vihanen ja sano et sen elämän pahin virhe oli se et anto teräsbetonille luvan julkasta kokoelma-albumin ja veti sitä turpaan, sit joku nerd innostu ihan vitusti koska vaan pekka poudan piti pystyy luomaan ukkosta, sit kansliassa kämpänneet kodittomat nuoret pakeni piiloistaan koska ne pelkäs et sale hakkaa ne


My patient is medflighted and arrives on my unit intubated on 2 pressors. BP 62/45, nodding head appropriately and following commands. 2 more pressors added. Physician states this patient won’t make it two more hours. 30 years old, 6 kids, attempted suicide. I look at physician and say" this patient is not dying on my shift. We are going to do all of the things.“ After 8 hours, 10 liters of fluid, albumin, electrolyte replacement, bicarbonate infusion. A very tired me gives report that the patient’s systolic BP is finally above 90. The patient is able to follow commands the whole night. During the day pressors are weaned off and patient is extubated. Life saved. 3 nights later, 89 year old patient down time of 90 minutes between several episodes of v fib arrest. Intubated, On 2 pressors, completely unresponsive with no sedation. Physician states, we are doing all the things! Me looks at family, what are this patients goals at the end of life. Family talks, we withdrawal care administering morphine and lorazepam for comfort of patient and family. Patient passes peacefully surrounded by family. A very tired me gives report in the morning. Life not saved. My husband thinks I’m crazy because sometimes I get mad when the physician wants to do all the things and sometimes I get mad when they don’t want to do all the things. I find that advocating for the patient in either capacity is exhausting.

  • blood 血液 けつえき or 
  • blood transfusion 輸血 ゆけつ
  • blood donation 献血 けんけつ
  • whole blood 全血 ぜんけつ
  • red cell or erythrocyte 赤血球 せっけっきゅう
  • platelet 血小板 けっしょうばん
  • plasma 血漿 けっしょう or プラズマ
  • cryoprecipitate 寒冷沈降物 かんれいちんこうぶつ or クリオプレシピテート
  • centrifuge (noun) 遠心機 えんしんき
  • centrifuge (verb) 遠心する えんしんする
  • white cell or leukocyte 白血球 はっけっきゅう
  • electrolyte 電解質 でんかいしつ
  • plasma protein 血漿タンパク質 けっしょうたんぱくしつ
  • albumin アルブミン
  • alpha globulin αグロブリン あるふぁぐろぶりん
  • beta globulin βグロブリン べーたぐろぶりん
  • osmotic pressure 浸透圧 しんとうあつ
  • gamma globulin γグロブリン がんまぐろぶりん
  • fibrinogen フィブリノーゲン or フィブリノゲン or 線維素原 せんいそげん
  • haemostasis 止血 しけつ or うっ血 うっけつ
  • collagen fibre コラーゲン線維 こらーげんせんい or 膠原線維 こうげんせんい
  • clot 血餅 けっぺい
  • coagulation 凝固 ぎょうこ
  • fibrin フィブリン or 線維素 せんいそ
  • haemophilia 血友病
  • blood type 血液型 けつえきがた
  • glycoprotein 糖タンパク質 とうたんぱくしつ or グリコプロテイン
  • antigen 抗原 こうげん
  • agglutinogen 凝集原 ぎょうしゅうげん
  • universal recipient 万能受血者  ばんのうじゅけつしゃ
  • universal donor 万能ドナー ばんのうどなー or 万能給血者 ばんのうきゅうけつしゃ
  • Rhesus blood group Rh式血液型 あーるえっちしきけつえきがた
  • Rh positive Rh抗体陽性 あーるえっちこうたいようせい or Rh陽性 あーるえっちようせい or Rhプラス 
  • Rh negative Rh抗体陰性 あーるえっちこうたいいんせい or Rh陰性 あーるえっちいんせい or Rhマイナス
More diabetes vocabulary
  • 排泄 はいせつ  excretion
  • 尿中アルブミン にょうちゅうあるぶみん  urine albumin
  • 糸球体 しきゅうたい  glomerulus
  • 自覚症状 じかくしょうじょう  subjective symptoms
  • 食欲不振 しょくよくふしん 
  • 減塩 げんえん  loss of appetite; anorexia
  • 司る つかさどる  to rule; to govern; to administer
  • 胃にもたれる  sit heavy on the stomach
  • 便秘 べんぴ  constipation
  • アルドース還元酸素阻害薬 あるどーすかんげんこうそそがいやく  aldose reductase-inhibitor 
    • 還元酵素 かんげんこうそ  reductase 
  • 認知症 にんちしょう  cognitive impairment; senility; dementia
  • 除去 じょきょ  removal
Explained to a surgical PA what SVRI meant..

Called the PA because my BP was low. Explained the CVP was high normal, CO/CI were within normal limits, but my SVRI was 600. He said “Okay lets give a dose of Albumin.” I said “I feel like Albumin won’t help with the low SVRI. Could you consider some Levophed?” He said “What does SVRI mean again?”

Originally posted by ramblingcoffeedrinkinggamer

If you see one of these listed then the product is not *vegan:

• Carmine/cochineal (E120) – red pigment of crushed female cochineal beetle, used as a food colouring
Casein – from milk (a protein)
• Lactose – from milk (a sugar)
Whey – from milk. Whey powder is in many products, look out for it in crisps, bread and baked products etc.
• Collagen – from the skin, bones, and connective tissues of animals such as cows, chickens, pigs, and fish – used in cosmetics
Elastin – found in the neck ligaments and aorta of bovine, similar to collagen
Keratin – from the skin, bones, and connective tissues of animals such as cows, chickens, pigs, and fish
Gelatine/gelatin – obtained by boiling skin, tendons, ligaments, and/or bones and is usually from cows or pigs. Used in jelly, chewy sweets, cakes, and in vitamins; as coating/capsules
Aspic – industry alternative to gelatine; made from clarified meat, fish or vegetable stocks and gelatine
Lard/tallow – animal fat
Shellac – obtained from the bodies of the female scale insect Tachardia lacca
• Honey – food for bees, made by bees
• Beeswax (E901) – made from the honeycomb of bees, found in lipsticks, mascaras, candles, crayons etc.
• Propolis – used by bees in the construction of their hives
• Royal Jelly – secretion of the throat gland of the honeybee
• Vitamin D3 – from fish-liver oil; in creams, lotions and other cosmetics
Lanolin (E913) – from the oil glands of sheep, extracted from their wool – in many skin care products and cosmetics
• Albumen/albumin – from egg (typically)
Isinglass – a substance obtained from the dried swim bladders of fish, and is used mainly for the clarification of wine and beer
Cod liver oil – in lubricating creams and lotions, vitamins and supplements
• Pepsin – from the stomachs of pigs, a clotting agent used in vitamins

Pre-eclampsia / Eclampsia

Risk factors:

  • >35 year old
  • Primip
  • Multiple pregnancies
  • Molar pregnancies
  • Pregnancy induced hypertension (PIH)
  • Previous PIH
  • Family Hx of PIH
  • Pre-existing hypertension, renal disease, autoimmune disease

Hx should include:

  • When was the diagnosis of pre-eclampsia, what was the treatment, compliance to treatment, ongoing monitoring
  • Sxs - headache, blurry vision, epigastric pain, nausea (signs of impending eclampsia)
  • Fetal movements?
  • Per vaginal bleed?
  • Growth of fetus / AFI scans / fetal scans till date
  • Current gestational age

Physical Examination:

General - Vital Signs! Height, weight (look out for trend increase), pallor, petechiae, edema

Lungs - crepitations sec. to pulmonary edema

Abdomen - SFH, liquor volume, obvious fetal movements, scars, estimated fetal weight, woody hard uterus - indicative of placenta abruptio

Neuro - Hyperreflexia, clonus

Fundoscopy - hypertensive changes


- Urine dipstick, 24 hour urine collection (albumin measure)

- FBC - Hb (anaemia), Platelets (low? <100)

- U/E/Cr - Renal function / metabolic derangements? / 

- Uric acid

- LFT - Look at AST / ALT (elevated > x2?)

- GXM - blood group and cross match

- Ultrasound - Estimated fetal weight, amniotic fluid index


For mild to moderate pre-eclampsia, monitor closely as outpatient.

  • Counsel patient: what is pre-eclampsia, dangers of pre-eclampsia, can be cured via delivery, return of BP to normal within 6 weeks post partum
  • Pharmaco: methyldopa to control hypertension
  • Monitor: Blood pressure, Urine dipstick, keep a diary
  • Discuss about sxs of impending eclampsia - headache, blurry vision, epigastric pain, nausea - to come to hospital immediately, or if blood pressure uncontrollable, increasing trend in proteinuria
  • Follow-up: weekly! - BP measurement, urine dipstick, fetal ultrasound, physical examination
  • Re-assure patient

For severe eclampsia

  • CALL FOR HELP - Senior Obs/MO/Registrar, Labour room sisters, Anaesthetist/Operating theatre (Emergency LSCS)
  • Start Pre-eclampsia chart (Vitals - BP/PR, Weight, edema, urinary albumin levels, fetal movement/HR, input/output chart)
  • CTG - monitor baby
  • Anti-hypertensives : methyldopa (slow acting) / Hydralazine (fast acting) - be careful of quick drop in BP. Provide IV fluids if BP dropping too quickly. Do not give fluids if evidence of pulmonary edema
  • Seizure prophylaxis: MgSO4 ! S/e: palpitations, hypotension, flushing, sweating. Toxicity: Renal failure, respiratory depression, hyporeflexia. Antidote: Calcium gluconate. Monitor Levels! 
  • Plan for delivery: LSCS vs Normal vertex delivery. Indications for delivery: fetal compromise (abnormal CTG, abnormal doppler, IUGR, AFI <5), maternal compromise (placenta abruptio, end-organ damage - oliguria, HELLP syndrome, signs + sxs of impending eclampsia), dexamethasone, 
  • Intrapartum - continue MgSO4 till 24hours postpartum (14% seizures can occur postpartum), control BP, LSCS if fetal compromise
  • Postpartum - monitor resolution of blood pressure, monitor renal function and resolution of biomarkers (LFTs, FBC - platelets), refer physician if still hypertensive and/or proteinuria
  • Counsel - reoccurrence in subsequent pregnancies. if severe pre-eclampsia, 30% can reoccur in future pregnancies

So I was refilling my random word list and came across this:

Bois durci

Definition: A hard highly polishable composition made of fine sawdust from hard wood as rosewood mixed with blood and pressed

And WTF? A bit of googling showed that this was apparently an early form of plastic that was quite popular in Victorian times for making all sorts of ornamental objects:

The things you learn on the internet!

For the record, apparently it was the albumin from cattle blood that they mixed with the sawdust and now I am having some horrible ideas about Obi-Wan and Bantha related crafts…

Why use apps when you can use your brain- some formulae you need in internal medicine

Fluid and electrolyte
USA- Serum Osmolality = (2 x (Na + K)) + (BUN / 2.8) + (glucose / 18)
UK-  Serum Osmolality = (2 x (Na + K)) + Urea + Glucose
Normal range:  285 - 295

Corrected Na
UK- Corrected serum Na= (RBS-5.5)/5.5 x 1.6 + measured Na- for the first 22mmol/L
Corrected serum Na= (RBS-22)/5.5 x 2.4 + measured Na- for value after 22mmol/L
USA- Corrected serum Na= (RBS-100)/100 x 1.6 + measured Na- for the first 400mg/dL
Corrected serum Na= (RBS-400)/100 x 2.4 + measured Na- for value after 400mg/dL

Corrected Ca
UK- Corrected serum Ca = 0.02(40-Albumin (g/L)) + measured Ca
USA-  Corrected serum Ca = 0.8 (4- Albumin (g/dL) + measured Ca

Cockroft Gault formula
UK- eGFR= [(140- Age) x body weight x constant] / serum creatinine ( umol/L)
constant- 1.23 for male and 1.05 for female 

Urine output
Urine output (/kg/hr) = total output / IBW / Hours

Smoking pack years
Smoking pack years  = (Cigarettes per day x years)/ 20

Ideal body weight 
Inches and foot (in US)
Male: 106 lbs for 5 ft tall;  Add 6 lbs/in above 5 ft
Female: 100 lbs for 5 ft tall;  Add 5 lbs/in above 5 ftThis is easy.

Cm and Kg (outside US)
Male: Wt [kg] = 50.0 + 0.91 (Ht [cm] - 152.4)
Female: Wt [kg] = 45.5 + 0.91 (Ht [cm] - 152.4)

Mean Arterial Pressure
 MAP= Diastolic BP + (1/3)(Systolic BP- Diastolic BP)
        =  [2 Diastolic BP + 1 Systolic BP]/3

Acid base
Henderson Hasselbalch formula 
pH= 6.1 + lg [HCO3/0.03PCO2]

Prediction of compensation
Met acidosis- Winter formula  CO2 = 1.5 x HCO3 + 8 +- 2
Met alkalosis = increase in CO2 = increase in HCO3 x 0.7 
Respiratory acidosis
-Acute= 1 HCO3 for 10 CO2 increase
-Chronic= 3 HCO3 for 10 CO2 increase
Respiratory alkalosis
-Acute= 2 HCO3 for 10 CO2 decrease
-Chronic= 4 HCO3 for 10 CO2 decrease 

Anion gap= Na - (Cl+HCO3) normal range- 8-12
normal anion gap caused by albumin

Urine anion gap = (Na+ K) - Cl normal range- negative
normal urine anion gap caused by ammonium in urine

HCO3 before = HCO3 now + (anion gap - 12)


"If the liver can regenerate, how do people die of liver failure?"

I attempted to answer this question awhile ago, and I thought I’d post my answer here too. The liver fascinates me. I think because it’s really such a vital organ.

“Often the person dies before the liver has time to regenerate, like in acute liver failure. The liver does a lot of stuff for the body, so when it isn’t working properly it stuffs up a lot of other things. The combination of these things can unfortunately kill a person quite quickly, before the liver can fix itself or a new liver can be found. A damaged liver can affect:

How fast your blood clots (it will take longer in a patient with liver failure and so they can bleed easily and for long times, and will need lots of blood products to both replace the lost blood as well as shorten the clotting time of the blood)

Movement of fluid to the wrong areas of the body. The increased pressure caused by blood flowing through a damaged liver can cause the blood vessels to leak fluid out into the abdominal cavity, which is called ascities. A big belly can then cause pressure on the lungs and make it harder to breathe. On top of that, the shock that the body gets from having a sick organ can cause the body to leak fluid out of blood vessels all over, making them swollen in their arms and legs, and I’ve seen some enormous scrotums too… Because of all of this leakage, the blood pressure can drop to dangerous levels and patients often need blood products such as albumin to shift the fluid back into the blood vessels. Ascities can be drained too.

The brain doesn’t work properly, because the toxins that the liver should be getting rid of stay in the body and travel to the brain. People become confused, agitated, drowsy, and possibly comatose if it gets too severe.

Blood sugar levels drop. The liver stores glucose, and so when it isn’t working, you can end up with dangerously low blood sugar levels. Your brain needs glucose to function!

High pressures in your blood vessels in your liver can have an affect on the blood vessels around your oesophagus, causing oesophageal varices - abnormal vessels around your oesophagus that can burst. In combination with bad clotting blood, this can cause life-threatening bleeding.

The accumulation of fluid and high pressures in your belly can squash the kidneys and their blood supply. Low blood pressure can also affect the kidneys. Often, patients in acute liver failure will require continuous dialysis for awhile because their kidneys stop working.

As for those who have chronic liver failure, this kind of stuff happens but at a slower rate. Once the liver is scarred (cirrhosis) it cannot grow back.”

yankeecountess  asked:

DRABBLE REQUEST! In which Mary and Edith band forces along with their brother-in-law in getting Sir Philip Asshat away from their pregnant sister (and thus helping save Sybil's life)--I have a mighty need for some ferocious "big sisters protecting baby sister" feels

Mary and Edith could tell that things were not alright when everyone was called into the library, save for Tom who had gone upstairs to be with Sybil. The concern on Dr Clarkson’s face was unmistakable, and before he even said anything they knew there was veritable cause to worry.

“It’s my belief that Lady Sybil is at risk of eclampsia,” Dr Clarkson explained gravely. 

Robert looked to Sir Philip Tapsell for an answer. “What is that?”

Sir Philip scoffed. “A rare condition from which she is not suffering!”

Edith and Mary glanced cautiously at each other. They hardly knew what eclampsia was, but being this close to Sybil giving birth, it was probably nothing short of calamitous. 

Dr Clarkson began to describe Sybil’s predicament. “Her baby is small. She’s confused, and there’s far too much albumin – that is, protein – in her urine. The fact is if I am right, we must act at once!”

From behind Matthew touched Mary’s shoulder reassuringly, but it did nothing to assuage Mary’s fears. Dr Clarkson’s panic was unnerving everyone greatly, except for Lord Grantham and Sir Philip. “And do what?” she asked. 

“Get her down to the hospital and deliver the the child by Caesarean section,” Dr Clarkson answered immediately.

From the shared expression on Edith and Mary’s faces, both of them would have picked Sybil up and carried her to the village hospital by themselves. What were they doing here, sitting in the library while Sybil gasped in pain, when they could be acting at once to help her?

“But is that safe?” Matthew questioned.

“It can’t be any less safe than what she’s going through now,” Mary snapped. “She’s giving birth, for heaven’s sake, and if what Dr Clarkson is saying is true, she’s going to be in even more danger the longer we wait.”

“Lady Mary, please do not assume these things when you are not trained in medicine in the slightest,” Sir Philip retorted.

Mary looked as if someone had thrown a lump of cow dung at her dress.

“Forcing Lady Sybil through a Caesarean section is the opposite of safe,” Sir Philip objected. “It would expose mother and child to untold dangers! She could pick up any kind of infection at a public hospital!”

“An immediate delivery is the only chance of avoiding the fits that are brought on by the trauma of natural birth!” Dr Clarkson countered.

Mary and Edith looked at each other helplessly as the doctors shot their own theories back and forth – Sybil wouldn’t get any better with the two doctors arguing, and from the agitation in Dr Clarkson’s voice, they could sense that Sybil’s life was on the line as well as her unborn baby’s. 

“A Caesarean section is a gamble which might kill either or both of them,” Sir Philip nearly shouted. 

“But if there’s a chance she might live if she has this … Caesarean section,” Edith piped up, “wouldn’t it better to give her that chance rather than leaving things to fate.”

“We aren’t leaving things to fate, Lady Edith, there is no reason to put her through that operation,” Sir Philip growled. 

Robert, rubbing his ruddy face, finally said, “I think we must support Sir Philip in this.”

“But it’s not our decision!” Mary protested. She knew Sybil wasn’t in any state to confirm what she wanted, but her husband would know what was best for her. “What does Tom say?”

“Tom has not hired Sir Philip, he is not master here, and I will not put Sybil at risk on a whim here,” Robert insisted.

Simultaneously, Edith and Mary shot up from their seats. “Now just listen, Papa!” Mary exclaimed. “It is Sybil who is giving birth, not you, and it should be her who decides how things will go. But she’s confused and hardly knows where she is, but Tom knows her best and is the only other person that can decide for her.”

“It should have been Sybil’s choice about who treats her, besides,” Edith put in. “You never asked her. Like Mary said, it’s Sybil who is giving birth, it is she who should be listened to.”

“And I know for a fact she is ill,” Mary conceded. “She told me herself, she knew something was off. That was a couple of days ago.” She sighed in shame. “I should have said something then. Then maybe this whole farce could have been prevented.”

“But what matters now is that we help her now,” Edith said. “I’m sorry Papa, but I believe Dr Clarkson—”

“So you’d put your own sister at risk over nothing?” Robert asked.

“She’s already at risk by giving birth!” Mary yelled. “Look, we need to talk to Tom right now, and the longer we wait, the more likely I think that something bad will happen to Sybil! If not by giving birth, then by hearing that a bunch of doctors were arguing about her health and not asking her or her husband what should be done!”

That was enough to convince everyone to clamber up the stairs to the gallery and and practically pull Tom out of Sybil’s bedroom. Dr Clarkson explained the situation as best he could, but all Tom was interested in was if Sybil could be helped at all.

“Could we get her to the hospital?” he cried.

Sir Philip held up his hand. “To move her now would be tantamount to murder.”

Dr Clarkson was still trying to convince Sir Philip that Sybil was indeed in danger, but all Edith and Mary could care about was Sybil’s muffled gasping from behind the closed bedroom door and Tom’s distressed face. The two of them could agree on one thing – time was running out.

“We should be at hospital by now!” Dr Clarkson said. “If we acted at once, the baby would be born.” 

“But if she had the operation now, do you swear you can save her?” Tom asked. His cracked from his own panic.

“I cannot swear it, no,” Dr Clarkson admitted, “but if we do not operate and if I am right about her condition, then she will die!” 

“If, if, if, if – I’m telling you there’s no need!” Sir Philip shouted. “There is nothing happening, only that she’s about to give birth! Why put her through more risk?”

“This is ridiculous,” Mary muttered, her hands in her face. She didn’t care if a Caesarean section might not save her, but if they didn’t take every chance they had to save Sybil then that would be a shadow that lingered over their family forever.

“Tom, Dr Clarkson is not sure he can save her,” Robert tried to convince Tom. “Sir Philip is certain he can bring her through it with a living child. Isn’t a certainty stronger than a doubt?”

“And isn’t taking a chance better than doing nothing?” Edith interrupted. 

“Lady Edith, we are not doing nothing, we are simply not putting Lady Sybil through an unnecessary operation—” Sir Philip started to say.

Mary had had quite enough. She slapped Sir Philip across the face.

“I’ve had it! I don’t care what you think — Dr Clarkson knows Sybil, he knows her symptoms, she told me about them herself, and I don’t give a damn about the risk from an operation. I’d rather she die from the operation knowing that we did what we could to save her rather than let her die right now as all of us stood by and did nothing because our papa trusted the word of some pompous unfamiliar doctor rather than the doctor who’s known Sybil her entire life!”

“So you’d have her taken to hospital?” Tom asked.

“I’ll carry her myself if I have to!” Mary exclaimed. 

From within the bedroom came a loud, agonizing scream.

“God help us,” Tom whimpered, looking like he was going to pass out. 

“That is it!” Mary gestured to Edith. “Telephone for an ambulance right now and tell them to get here as fast as the engine can go! Dr Clarkson, if there’s anything you can do to help Sybil in the meantime, please do so!” 

Edith nodded quickly and bounded down the stairs. Mary rounded on her papa and a fuming Sir Philip. “And I suggest the two of you go back downstairs and have a bit of whiskey, and don’t do anything to get in anybody’s way.”

“Mary, you are being absurd,” Robert shouted. 

“Am I?” Mary glared. “Your youngest daughter is clearly ill and each moment you say nothing is wrong, the closer she comes to dying. Papa, you had no right to interfere! You know nothing about pregnancy or childbirth or Sybil’s desires! You just wanted to prove she was still a lady by putting that arrogant prat in charge of her well-being!”

She raced into Sybil’s bedroom, tears streaming down her face and Matthew following at her heels. Downstairs, Edith’s voice could be heard speaking into the mouthpiece of the telephone. 

At the cottage hospital, Dr Clarkson hastily preformed the operation, delivering a small but otherwise healthy baby girl. But Sybil hovered between life and death for several days.

Neither Mary or Edith could hardly eat or sleep for several days. Sybil and Tom’s little girl was sure to survive, but Sybil had barely had the operation done in time. Dr Clarkson estimated that if they had hesitated for a few moments longer, Sybil would have died on the operating table. For now, it was a matter of her regaining her strength, coming out of the coma that she had been in since she arrived at the hospital.

“You and Edith did the right thing,” Matthew said to Mary as they sat outside, on their bench underneath the great big tree. “You stood up for Tom and helped Sybil when no one else was doing anything. She’ll be eternally grateful to both of you.”

“Was it enough, though?” Mary asked. “Sybil’s so weak she can barely eat.”

“But you gave Tom a little girl, and the hope that his wife will live,” Matthew said. “He’s grateful as well that you acted in spite of the doctors. Your actions probably did more to save her than the operation.”

“I just couldn’t bear it,” Mary sobbed. “They were standing there, arguing while Sybil was screaming her head off. It didn’t matter if she was in any danger or not, I would have done anything and everything to make sure she was safe. Any chance to save her, even if it failed in the end, I would have taken it. She’s my little sister, and I know I couldn’t live with myself if she died and I didn’t do anything.”

“Well, if it’s any consolation, I’m glad you smacked that other doctor.” Matthew smiled faintly. “He was starting to get on my nerves. My father said once that a doctor that treated everything as perfectly normal was a bit too narcissistic to trust.”

Mary smiled a little bit, but it disappeared as Edith came running towards them. “We have to get to the hospital now.”

“Why?” Mary was frightened. “What’s happening?”

“It’s Sybil. She’s woken up.”

*Six months later*

Matthew, Mary and Edith stood at the platform of the train station, saying their goodbyes to the Bransons. Sybil looked better than she had in months, and now that Dr Clarkson had declared her fit to travel, she and Tom were leaving Downton as soon as they secured tickets for the ship to Boston.

“Is Fiona warm enough?” Edith asked as the little baby grasped her little finger. 

“I think she is,” Tom said, grinning. “She’s as happy as a clam.”

Sybil bounced her little baby in her arms. “She’ll like Boston, I think. So much excitement.”

She looked up at Edith and Mary. “I don’t know if I’ve made it clear just how grateful I am for the two of you. If it wasn’t for you, I don’t think either Fiona or I would be here today.”

“We did what we could,” Mary said. “It was Dr Clarkson who delivered your child.”

“But you were the ones who stepped in and took control. Edith, you phoned the ambulance, and Mary – well, you told that other doctor off. I never wanted him anyway.”

“As I said to Papa,” Mary said.

“Just know that, if ever I say another cruel word to either of you, I will never forget what you did for me, and for Tom and Fiona. I mean it,” Sybil promised. 

Mary touched Sybil’s arm tenderly. “We’re your sisters, and whatever happens we will look out for each other, no matter what.”

Sybil grinned. “I hope that still holds true now that you’re expecting.”

“Do you think I wouldn’t help Mary?” Edith asked. 

Sybil shook her head. “No, I know you would do anything to save her, just like you did for me.”

She handed Fiona to Tom before embracing both of her sisters. “God, I love you two so much.”

For all of their bickering and backstabbing, no one could deny that their sisterly love was capable of conquering all adversity. No one, not even a Harley Street doctor or the Earl of Grantham, could stand in their way.

The Domestic Life of Mr. and Mrs. Rogers - Part 1

Want some fluff? I’m going to start putting little Steve/Nat ficlets here, scenes of their domestic bliss that aren’t enough to be a whole story.  These aren’t related to HotS and will feature little plots and what-have-you that won’t occur there (although I might incorporate or borrow some of it, depending). All of these little stories will be rated in the G/Teen department, unless I say otherwise :-).

Anyway, happy Easter!

1. Easter

               When the bright spring sunlight hit them, there could be absolutely zero doubt that James was Steve’s son.  Everything from the highlights of hisperpetually mussed blond hair to the glow of his baby blue eyes to the build ofhis little body to the way he walked… Natasha wondered (not for the first time) if there was any part of her in him.  There probably was somewhere.  After all, she had pretty vivid memories of making him.  And birthing him.  So she’d made contributions to him.  But with her two boys out hunting in the park, James insisting on carrying his little basket with his father trying to help him without helping him, practically mirror images of each other… Well.

               “They’re like the same person,” Tony grumbled from beside her. Apparently great minds thought alike. He shook his head.  “Look at them.  It’s disgusting.”

               She was looking at them.  Looking at them and melting just a little more with each moment.  James had Steve’s expression of sheer determination tight on his face, his cheeks flushed, eyes narrowed in concentration as he scoured the grass and flower beds and bushes for Easter eggs.  He seemed oddly directed, like he knew where to look. From her vantage up the slight hill she couldn’t really see the eggs, but they could, and they were precise in their acquisition of them.  Tactical. She’d never been a big one for Easter (or most holidays, come to think of it), but this seriously brought cute to a level even she couldn’t deny.  James was toddling further down the little hill now, the top of his diaper peeking out from under his pants, and Steve was pointing something out to him in a thatch of grass.  He ran over, every step threatening to topple him, and stuck his chubby hand into the spot. Sure enough, he found yet another egg, this one pink.  She heard Steve say something to him, and he was quick to put it in his basket.  His basket that was already loaded thick with eggs of every color imaginable.  Were there any left for the tons of other kids roaming the park on the hunt?  Part of her felt guilty.  A pretty small part.

               “You know, if you’d have let me help, we could have been done with this, like, an hour ago,” Tony declared quietly to her.

               “Stark, we haven’t even been here an hour,” she reminded.

               “Yeah, well, the point is Banner and I had it all figured out.  We were gonna build this egg detector thing, you know, something that could sense albumin or I dunno…  Put it in a toy or something for James…  Something he could carry around without attracting suspicion.  It was going to be awesome.  He’d find all the eggs in record time.  Bam.  Done. We’re back home, having chocolate and beer.”  She shot Stark an incredulous glance that said Seriously? far better than she could actually say it.  “What?  Captain Stick-Up-His-Butt told me that wasn’t fair.”

               “It’s not.”

               “But it would be awesome.  And a very Black Widow approach.  Spy-like.” She had to admit that was true.  “Who would know?  And like it’s fair having Captain America for a father.  Look at that basket.  He can hardly lift it.  It’s ridiculous.”

               That was true.  And James being James wasn’t letting Steve do it for him.  He was trying to half lug, half carry it back up the hill all by himself. Definitely his father’s son.  Natasha smiled, dropped her arms from where they’d been folded across her chest, and waved.  “Well, it looks like they’re done.  So you can stop whining.”  Tony huffed a little.  Natasha couldn’t help but compare the state of James’ little basket to those of the other kids.  It was pathetic (and childish) but she was kind of proud to see that he did have more. “And it looks like they found every egg imaginable, so there.”

               “It’s about efficiency, Red.”

              As Steve and James got closer, she saw there’d been battle damage in James’ quest.  His little khaki pants had a couple of grass stains on the knees.  His cornflower blue polo shirt was untucked.  But that didn’t stop him from breaking into an all-out sloppy run when he saw his mother.  “Mama! Mama!”

              Natasha dropped to a crouch, her spring dress fanning out around her.  “Did you have fun?  What did you find?”

              “Eggs!”  He proudly held up his basket (or tried to), that huge sprawl of Steve’s grin on his face. “Look!  Look!”  All his L’s sounded like W’s.

              Natasha made a show of peeking through his treasure trove of eggs.  “Wow, baby. You found all of these?”

              He beamed.  “Daddy help.”

              “A little,” Steve agreed as he came up behind him. “He did most of it.”

              “Could have done better,” Tony sing-songed as he turned to head back to the car.

              “Cheating on an Easter egg hunt.  That’s a new low for you,” Steve reprimanded lightly. Tony waved him off.  Steve smiled devilishly, dropping his tone once Tony was out of ear-shot.  “Besides, who needs technology?”

              Natasha rolled her eyes, sweeping her hand through James’ hair before straightening his clothes a little.  “Tell me you left some for the other kids.”

              He shrugged.  “Some.”  She gave him a deadpan look.  “What? Not our fault that we’re really good at finding things, right, kiddo?” Steve crouched and hauled James’ giggling form up into his embrace.  James laughed and laughed, flinging his arms around his father’s neck as Steve manhandled him around a little before settling him against his side.  Then he wrapped his other arm around Natasha’s waist and pulled her against him, too.  His lips found hers in a kiss that was maybe not entirely proper for the occasion, but she didn’t exactly find herself stopping him.  Maybe there wasn’t a lot of her in their son, but she’d sure rubbed off on her husband.  “Found you, didn’t I?”

              She smiled, reached down, lifted James’ eggs, and shook her head.  “You sure did.”  And, on this perfect day, she was so very, very glad for that.

casiowristwatch-deactivated2014  asked:

Hi, I saw your recent post that had to do with the renal connections to the urinary system. I have Orthostatic Proteinuria-normal amounts of protein in a persons urine through the night, but an increase through the day. I was wondering if you could post about this semi-normal condition. Some questions like what are the causes, what does this mean for the future, or of any other effects. As far as I know, a good percent of the population has this, but for me, I am interested in more information.

Well, due to activity/standing/walking about during the day (leading to more muscle activity/breakdown), everyone’s urine protein content increases during the day, but in orthostatic proteinuria, it just increases more than what’s considered “normal”. Since there are no clinical signs of disease in this condition, most people who have it don’t know it, so it’s hard to say what exactly the long-term effects of it are, since we don’t really know the true percentage of healthy people who have it.

While someone who has this for their entire life is unusual, many people going through growth spurts or who have bodies still adjusting to adulthood end up showing increased albumin excretion (the primary protein excreted in urine) until their late 20s or early 30s.

If it persists beyond then, it appears to have a strong correlation with an increased risk of kidney stones (mitigated by never getting dehydrated) and may have an association with an increase in kidney disease/failure at 60+ years, but that is weaker with its correlation, and is not thought to be directly causative.

All in all, it seems to just be a variation on “normal” - most people who have it never experience any kidney problems or symptoms, and it often goes away in time.