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About 20% of human hearts exhibit shared coronary dominance order atarax with paypal anxiety 5 senses, such that both the right and circumflex arteries provide posterior descending branches buy 25mg atarax fast delivery anxiety problems. A: The right and circumflex arteries travel in the atrioventricular groove buy discount atarax 25mg on-line anxiety love, near the tricuspid and mitral valves atarax 10 mg fast delivery anxiety symptoms zenkers diverticulum, respectively (cardiac base). B: The anterior and posterior descending arteries travel in the interventricular groove and demarcate the plane of the ventricular septum (superior and inferior views). C: Coronary dominance is determined by the origin of the posterior descending branch. D: The anterior cardiac veins empty directly into the right atrium, whereas the other major epicardial veins drain into the coronary sinus. Nourishment for the right and left bundle branches is provided by other septal perforator branches of the anterior and posterior descending arteries. Similarly, the anterior and posterior descending coronary arteries course within the interventricular grooves and indicate the plane of the ventricular septum. Consequently, for surgeons and pathologists, the epicardial coronary arteries are reliable external landmarks for determining relative chamber sizes and valve locations. Coronary Veins The coronary veins and cardiac lymphatics work in concert to remove excess fluid from the myocardial interstitium and the pericardial sac. The venous circulation of the heart consists of a coronary sinus system, an anterior cardiac venous system, and a thebesian venous system (Fig. The great cardiac vein travels beside the left anterior descending and circumflex coronary arteries to merge with the coronary sinus. The coronary sinus, in turn, receives the left-posterior, middle, and small cardiac veins, as well as several smaller tributaries, before joining the right atrium. Along the anterobasal aspect of the right ventricular free wall, three or four anterior cardiac veins either empty directly into the right atrium or first join a common collecting vein. Finally, numerous small thebesian veins drain directly into a cardiac chamber, particularly the right atrium or right ventricle. The right atrium contains three valves (of the fossa ovalis, inferior vena cava, and coronary sinus). Cardiac Lymphatics Within the ventricular myocardium is an interconnecting network of delicate lymphatic channels that drain toward the epicardial surface. Along the epicardial surface, the right and left lymphatic channels form and accompany their respective coronary arteries in retrograde fashion toward the aortic root. These are joined by lymphatic channels from the conduction system and a few sparse lymphatic vessels from the atria and the valves (27). As the right and left lymphatic channels coalesce, they travel along the ascending aorta to the undersurface of the aortic arch and drain into a pretracheal lymph node. Next, they course between the superior vena cava and the brachiocephalic artery to join a cardiac lymph node before emptying into the right lymphatic duct. Lymphatics from the parietal pericardium drain into either the right lymphatic duct or the thoracic duct. Its function is influenced by sympathetic and parasympathetic innervation, circulating catecholamines, patency of its nutrient blood supply, regional acid–base or electrolyte disturbances, mechanical trauma (such as sutures, synthetic patches, or ablation procedures), and involvement by neoplasm or infection. All components of the cardiac conduction system are specialized cardiac myocytes, not nerves, whose major function is conduction rather than contraction. Because it is found at the border between areas derived from the sinus venosus and the embryonic atrium, the pacemaker is often referred to as the sinoatrial node. It is shaped like a flattened ellipse, through which a prominent sinus nodal artery passes. Microscopically, the node is characterized by a complex interwoven pattern of P cells and transitional cells, within a fibrous stroma, and an outer coat of working atrial myocytes (28). Because these specialized cells are primarily concerned with conduction rather than contraction, they have fewer contractile elements and expend less energy than working myocytes. Although P cells are thought to be the source of impulse formation, changes in autonomic input may alter the actual pacing site within the node. Among patients with the asplenia syndrome and right isomerism, bilateral sinus nodes may be encountered. In contrast, in the setting of polysplenia and left isomerism, the sinus node can be congenitally absent or malpositioned. During surgical operations such as the Mustard and Fontan procedures, the sinus node and its artery are susceptible to injury. Electrophysiologic studies support the concept of preferential pathways, but morphologic studies do not. The three internodal tracts identified electrophysiologically correspond to those regions of the atrial septum and right atrial free wall, such as the crista terminalis, that contain the greatest concentration of myocytes. Thus, microscopically, these regions consist of working atrial myocytes rather than specialized P, transitional, or Purkinje cells. Because the septal preferential pathways near the fossa ovalis travel anterosuperiorly in its limbus, internodal conduction disturbances would not be expected following a Rashkind balloon atrial septostomy, in which the valve of the fossa ovalis is torn, or a Blalock–Hanlon posterior atrial septectomy. However, for operations in which the atrial septum is resected, as in the Mustard and Fontan procedures, such disturbances can occur. Similarly, disruption of the crista terminalis may interfere with normal internodal conduction. In contrast, it is located subendocardially, rather than subepicardially, within the triangle of Koch and adjacent to the right fibrous trigone (or central fibrous body). Centrally, the node is more compact and is characterized by an interlacing arrangement of P cells. A: The sinus node lies subepicardially in the terminal groove of the right atrium (right lateral view). C: The right bundle branch is a small cordlike structure that courses along the septal and moderator bands (opened right ventricle). D: In contrast, the left bundle branch represents a broad sheet of fibers that travels subendocardially along the left side of the ventricular septum. It thereby represents the only normal avenue for electrical conduction between the atrial and ventricular myocardium. Thus, during operative procedures involving these valves or a membranous ventricular septal defect, care must be taken to avoid injury to the His bundle. Both regions are characterized by numerous parallel bundles of Purkinje cells and working ventricular myocytes, separated by delicate fibrous tissue (28). During fetal and neonatal life, these conduction bundles are often dispersed or separated within the central fibrous body. The final destination of each bundle within the right or left ventricle is probably determined by its position proximally within the penetrating portion of the His bundle. These accessory pathways are apparently nonfunctional in most individuals, although they may produce ventricular preexcitation in some. Such bypass tracts can be single or multiple and may be identified by electrophysiologic mapping.
The government should be contacted to request any assistance in the form of search and rescue personnel and equipment proven atarax 25mg anxiety ocd. Structural engi- neers should be contacted to see if anything can be potentially done to block remaining water from escaping dams that have already failed by adding addi- tional barriers to the damaged areas purchase discount atarax line anxiety symptoms going crazy. All search and rescue personnel and equipment should now be mobilized as well as medical resources and engineering support order atarax 10 mg line anxiety nursing diagnosis. You should begin to take an inventory of all facilities that can house medical resources as well as housing displaced residents order atarax 10 mg on line anxiety 5 senses. With such a large population, you will also need to fnd resources for food, water, sanitation, and medicine for those individuals. Stage 4 of the Disaster You have now learned that communications were completely inadequate or had failed completely. You have received word that signal fares were not seen, tele- graphs were never sent or completed in transmission, and several couriers were lost in the rush of water. In addition, other dams have failed or have been bombed by the military to reverse the water fow, communication lines are nonexistent, electricity has been lost over wide parts of the region, transportation lines have 68 ◾ Case Studies in Disaster Response and Emergency Management been completely severed, and you have over a million people who are isolated by foodwaters (Watkins, 2012; Navarro, 2008). After several days it has now been reported that over 200,000 are dead from the food, with several communities wiped from the face of the earth (Navarro, 2008; Watkins, 2012). You will need to get the million or so people out of the isolated area or get some type of transportation line open to them so that food and other supplies can be sent to them before famine occurs. The infrastructure will need to be fxed quickly so that supplies, people, and engineers can begin to repair the dams and evacuate anyone in need from the area. Another issue that will now have to be dealt with is collecting and stor- ing the corpses so that drinking water and other areas are not contaminated. Tis will require facilities that are undamaged to be designated as a repository so that bodies can be stored and eventually identifed. Until the communication infrastructure is operable, you will need to rely on couriers to send and receive any type of messages. Terefore, a priority should be placed on getting engineers working to restore the telecommunication lines and switching. Tis will also require getting the power restored since telecommunications is reliant on electricity in order to function. Until transportation infrastruc- ture such as roads and railroads is repaired, you will have to rely on aircraft or boats to deliver supplies and perform search and rescue operations. Medical resources will be needed not only to treat the wounded, but also to treat individuals for disease that could have come into contact with contaminated drinking water. Safe drinking water must be made available to all of the displaced persons, support personnel, and individuals that are cut of and isolated by foodwaters. Key Issues Raised from the Case Study Tis case study presents an emergency manager with a communications nightmare. The communication that exists is rudimentary, and the mode of communication (telegraphs) is limited to those communities that have access to such devices. China in 1975 would be considered a developing nation since the majority of the population in rural areas did not have access to telephones or any type of electronic communications that were available to residents in cities. The situation today in many developing countries is much the same, and emergency managers in this type of situation will need to develop redun- dant and robust strategies for communicating with their governmental agencies as well as the population that will be impacted. Conditions seen in this case study in the forms of communication mirror the communication gaps that existed in the Newfoundland hurricane in 1775. In addition, government ofcials appeared to Case Studies: Disasters from Natural Forces—Floods ◾ 69 be overconfdent in the dams that were constructed, which proved to be fatal since there were no apparent emergency management plans in place if a food were to occur. Emergency managers should always prepare for the worst-case scenario and be prepared to execute their plans to prevent or at least diminish the tragedy that can befall a community. Items of Note Eleven million residents were afected by the food, and the reconstruction of the Banqiao Dam was not completed until 1993 (Watkins, 2012; Mufson, 1997). Additionally, more residents were killed by epidemics and famine than by the food itself (Navarro, 2008). Chapter 5 Case Studies: Disasters from Natural Forces—Tornadoes Natchez Tornado, Mississippi, 1840 Stage 1 of the Disaster You are a county commissioner for a port city in the southern region of the United States. On May 7, you are inspecting a county road when you notice a big funnel-shaped cloud over the horizon (Tornado Project, 2007). Your frst plan of action should be to warn every- one in your area to take cover since a tornado is visible and coming in the direction of your community. Tird, you should put all county and local personnel on alert as well as start identifying the locations of resources that you may need at a later time. Your communication plan should consist of sending out alerts to your community to take cover and to notify all frst responders as well as county and local ofcials that a tornado has been seen and is coming in the direction of your community. In this early stage of the disas- ter, you should mobilize personnel to get word to the community that a tornado is on the way and that the citizens should take shelter immediately. Stage 2 of the Disaster The town of Natchez has been hit forcefully by a Force 5 tornado (Tornado Project, 2007). As one of the chief administrators, how will you attempt to protect the citizenry of the town? First, you should get an accurate assessment of what parts of Natchez were damaged or destroyed so you can send your frst responders to where help is needed the most. Tird, your medical personnel and facilities need to be activated and ready to receive casualties, because with that much damage, there will be injuries among your citizens. You need better intelligence on the situa- tion, so you need to set up a command post where messages can be received and sent to the surrounding areas. Also, if it is possible, you should notify other counties or localities in the area that a tornado could potentially be heading in their direction. If possible, you should try to accumulate additional resources in the form of more frst responders, medical assets, and engineers to help shore up structures that are in danger of collapsing or to assist with rescue eforts of persons that are trapped under- neath rubble and debris. Stage 3 of the Disaster The town of Natchez has had approximately 48 people killed at this point. The tornado is beginning to move down the river and is beginning to sink a number of ships that are tied up along the river (Tornado Project, 2007b). The winds are so strong that the ships and their crews are literally being fipped up in the air, and then the crews end up drowning in the river (Nelson, 2004). If at all possible, you should attempt to evacuate all persons that are on board the ships. Additionally, you need to try to get as many people as possible to shelter that are in the path of the tornado. The tornado still has force behind its winds and is still quite capable of killing or injuring people. The main concern right now should be to communicate with persons that are in the path of the tornado to alert them that a tornado is coming and that they should evacuate the area. Case Studies: Disasters from Natural Forces—Tornadoes ◾ 73 Stage 4 of the Disaster The tornado has killed an additional 269 people along the river, along with the destruction of several ships in the river (Tornado Project, 2007). Your hospitals are overfowing with wounded as the count of injured persons now stands at 109 (Tornado Project, 2007).
Comparison of cardiac output determined by different rebreathing methods at rest and peak exercise buy atarax us anxiety symptoms neck tightness. Noninvasive assessment of hemodynamic responses to exercise in pulmonary regurgitation after operations to correct pulmonary outflow obstruction buy atarax no prescription anxiety symptoms chills. Cardiac output in exercise by impedance cardiography during breath holding and normal breathing buy discount atarax 10mg anxiety episodes. Influence of cardiac functional capacity on gender differences in maximal oxygen uptake in children purchase atarax on line amex anxiety symptoms getting worse. Measurements of cardiac output during constant exercise: comparison of two non-invasive techniques. Non-invasive cardiac output evaluation during a maximal progressive exercise test, using a new impedance cardiograph device. Application of bioreactance for cardiac output assessment during exercise in healthy individuals. Reliability of peak and maximal cardiac output assessed using thoracic impedance in children. Kimball Despite increasing use of complimentary imaging modalities such as computed tomography and magnetic resonance imaging (1,2), echocardiography remains the principal diagnostic modality in the field of pediatric cardiology (3). In addition, pediatric imagers face two important challenges today: (a) To define the complementary roles of echocardiography and the other imaging technologies in the evaluation of congenital heart disease patients (4) and (b) to oversee the expanding utilization of echocardiography among cardiology colleagues and noncardiology healthcare providers—utilization precipitated by poorer auscultatory skills of personnel and increased miniaturization and decreased cost of cardiac ultrasound technology (5,6). History In 1877, 18-year-old Pierre Curie found the basis for the field that would later be known as ultrasound by discovering the piezoelectric effect in which mechanical distortion of crystals produces an electric potential and vice versa. Although this was a landmark discovery, it was not until many years later, in fact not until after the 1912 sinking of the Titanic (which catalyzed efforts to create systems aiding ships in earlier detection of icebergs), that the field of ultrasound began to develop (7). The Colorado group developed B (brightness)- mode imaging, a method of displaying the intensity of the reflected ultrasound waves as dots of various brightness along a single scan line, the progenitor to two-dimensional (2-D) ultrasound. The Minnesota group perfected pulsed ultrasound techniques that permit a single transducer to act as both a transmitter and a receiver in real time and, by incorporating a water interface in the transducer head, creating the first hand-held scanner, thus eliminating the need for patient immersion (7,8). Applying ultrasound for cardiac diagnosis was first performed at the University of Lund, Sweden (Edler and Hertz) in 1953. A B-mode detector with continuous moving film to obtain real-time images of the heart in waveform provided the first M(motion)-mode echocardiogram (7,8). Twenty years later, M-mode echocardiography was applied to congenital heart disease by Goldberg, Allen, Sahn et al. In the late 1970s and early 1980s, the application of 2-D echocardiography to congenital heart disease allowing complete, accurate, and detailed diagnoses was successfully completed by pioneers such as Sahn, Snider, Silverman, Williams, Stevenson, and others (11,12,13,14,15,16,17,18,19,20). In the 1990s, ultrasound technology became increasingly miniaturized so that echocardiography began to enjoy even broader use including as a bedside adjunct to the physical examination in more unique settings such as the emergency room and the intensive care unit. With the advent of the new century, echocardiographers are employing increased use of three-dimensional (3-D) echocardiography and more sophisticated tools in the evaluation of ventricular function. A sound wave requires a deformable medium for its propagation because it is mechanical in nature, consisting of a series of compressions and expansions (rarefaction) of the molecules in the medium. The velocity of this sound wave depends on the type of tissue through which it is traveling (1,540 m/s in soft tissue, 330 m/s in air). The echocardiographic transducer does not emit ultrasound continuously but rather emits pulses rapidly (∼1,000 pulses/s) and quickly (∼1 ms for every pulse). Therefore, the transducer is operating as a transmitter for an extremely short time (0. During a 30-minute examination, the transducer will have transmitted pulses for <2 seconds. Eight Equations that Form the Basis of 2-D and Doppler Echocardiography Equation 1: The Basis of Image Generation where %R = percent reflection of ultrasound signal Zn = impedance in mediumn = ρncn ρn = density of mediumn cn = speed of sound in mediumn As an ultrasound beam travels through the body, some of its energy will be reflected back to the transducer and some of P. Consider the well-known novelty of a set of metallic balls suspended adjacent to each other as a pendulum (Fig. When an outside ball of sufficient mass is drawn away from the stationary balls and released, it strikes the stationary balls, resulting in the outside ball on the opposite side to move away from the stationary balls. If the first outside ball were, however, the size of a pea, it would strike the stationary balls and merely bounce away from them. It does not have sufficient momentum (because of relatively small mass) to cause any perturbation in the stationary balls. Sound travels with a velocity (c) dependent on the medium through which it propagates (for soft tissue, c = 1,540 m/s). The frequency (υ) is the number of compressions per unit of time expressed in Hertz. The frequency and wavelength are inversely proportional to each other through the velocity of sound (υλ = c). Therefore, the spatial pulse length is the distance from the beginning of a single pulse train to its end. Acoustic impedance is the ultrasound equivalent to momentum; tissue density replaces mass, and speed of sound replaces velocity (21). If the tissue density is the same between two media (the equivalent of a large metallic ball in the example above), the impedance between the two media is similar and ultrasound will be readily transmitted through the media interface; however, a mismatch in the tissue density between the two media (e. It strikes the stationary balls, resulting in movement of the outside ball on the opposite side. The ball has sufficient momentum to cause effective energy transfer to the stationary balls. B: After an outside ball of smaller size is released, it strikes the stationary balls and is reflected off of them. If the impedances between two media are similar, ultrasound will be readily transmitted. A bat feeding at twilight emits ultrasound waves at a frequency of 100 kHz, which provides excellent resolution for catching insects in air (λ = c/υ = 330 m/s ÷ 100,000 cycles/s = 3. With pulsed ultrasound, the axial resolution is dependent not only on the wavelength but also the number of wave cycles in that ultrasound pulse. The best possible axial-point separation resolution is equal to 1/2 of the spatial-pulse length (Fig. The poorer axial resolution of a transducer of this frequency therefore limits its usefulness in evaluating anatomy of smaller magnitude, for example, the luminal diameter of a coronary artery. For a nonfocused transducer, the ultrasonic beam consists of a near field with narrow beam width and good lateral resolution (the Fresnel zone) and a far field where the beam width diverges rapidly limiting resolution (the Fraunhofer zone) (21). The depth of the near field (with best resolution) is extended by increasing the frequency or the footprint diameter of the transducer (Equation 3 and Fig. For the parasternal and apical views, a small-diameter, high- frequency probe is advantageous because the cardiac structures are at a near depth P. For subcostal imaging, a larger-diameter transducer provides great advantage by extending the near field to the relatively deep depth of the cardiac structures improving their resolution. Lateral resolution can be improved by focusing which causes the beam width to narrow more distally where it would otherwise begin to diverge. Focusing can be accomplished by external devices (such as mirrors or lenses) or by electronic means; however, focusing results in greater far-field divergence than with a nonfocused beam. Equation 4: The Yin–Yang Relationship Between Resolution and Penetration where L = intensity attenuation loss (in decibels) μ = intensity attenuation coefficient ∼0. Attenuation describes the loss of intensity resulting from scattering (reflection at small interfaces) and absorption (energy transformation) (21).
Current data favors universal screening in view of increased risk of fetal loss in patients with untreated subclinical hypothyroidism and improvement in pregnancy outcome with levothyroxine therapy atarax 10 mg line anxiety back pain. Although fetal neurocognitive development may be impaired in patients with untreated sub- clinical hypothyroidism buy cheap atarax 10mg line anxiety home remedies, there is insufﬁcient data to show improvement in these parameters with treatment purchase generic atarax on-line papa roach anxiety. Free T4 should be estimated by equilibrium dialysis as other available methods lack precision purchase genuine atarax on line anxiety symptoms vs adhd symptoms. However, non-availability and difﬁcult assay technique precludes the routine use of equilibrium dialysis. An alternative to free T4 esti- mation is to multiply the normal reference range of total T4 for non-pregnant population by one and a half time. Maternal risks associated with subclinical hypothyroidism are miscarriage, pre- term delivery, and stillbirths, whereas fetal risks include low birth weight and possibly impaired neurocognitive development. Is treatment recommended for all women with subclinical hypothyroidism during pregnancy? Treatment of subclinical hypothyroidism during pregnancy is associated with favorable maternal outcome. However, the effect of maternal subclinical hypothyroidism on fetal neurocognitive development is not so clear. Theoretically there is an increased risk of cognitive dysfunction in these new- borns but data regarding improvement in cognitive outcome with levothyroxine in children born to mothers with subclinical hypothyroidism is not robust. However, ethically it is not appropriate to withhold a treatment having virtually no adverse effects. The data regarding pregnancy outcome with the use of low dose levothyroxine in such subset of patients is variable. Available guidelines also do not support the use of levothyroxine in these patients. Should medical termination of pregnancy be considered in a patient with hypothyroidism detected during pregnancy? Maternal T4 is essential for neural growth and development during ﬁrst trimester, as fetal hypothalamo–pituitary–thyroid axis is functional only after 10–12 weeks of intrauterine life. Deﬁciency of maternal T4 theoretically signals a poor neurological outcome, but the available literature in women with sub- clinical as well as overt hypothyroidism do not consistently support this risk. Hence, in women with subclinical or overt hypothyroidism detected any time during pregnancy, medical termination is not recommended. However, in preg- nant women having severe T4 deﬁciency with a history of previous child with mental/physical handicap/congenital malformation, especially from an iodine deﬁcient area, the decision regarding medical termination of pregnancy can be taken after a detailed discussion with both parents. Hypothyroidism, whether subclinical or overt, is associated with recurrent mis- carriages due to impaired folliculogenesis, luteal phase defect, and senescent ova fertilization as a result of aberrant gonadotropin secretion. Other causes of poor pregnancy outcome in hypothyroidism include ges- tational hypertension and placental abruption. Concurrent presence of other autoimmune disease like anti-phospholipid anti- body syndrome and celiac disease may further contribute to bad obstetric history. Patients receiving therapy for overt/subclinical hypothyroidism prior to con- ception should be advised to increase the dose of levothyroxine by 30–50% at 4–6 weeks of gestation. In the index case the dose of levothyroxine was increased to 125 μg/day, and she was advised to take iron and calcium supple- ments 6–8 h after intake of levothyroxine as they interfere with the absorption of levothyroxine. Subclinical hyperthyroidism during pregnancy does not require treatment as it is not associated with adverse maternal or fetal outcome because serum free T4 levels are within the normal range. Moreover, incidence of pregnancy-associated hypertension has been shown to be lower in those with subclinical hyperthy- roidism. Further, treatment may be detrimental as it may result in fetal hypothy- roidism because antithyroid drugs readily cross the placenta. Failure to gain weight, heat intolerance, excessive sweating, and tachycardia disproportionate to duration of gestation are the clues which suggest thyrotoxi- cosis during pregnancy. Gestational thyrotoxicosis is a transient, self-limiting, non-autoimmune hyper- thyroidism which usually manifests between 10 to 16 weeks of gestation. If gestational thyrotoxicosis is associated with severe nausea, vomiting, weight loss, and ketonemia/ketonuria, it is called as gesta- tional thyrotoxicosis with hyperemesis gravidarum. Gestational thyrotoxicosis should be differentiated from Graves’ disease as the management is primarily symptomatic in the former due to the self-limiting nature of illness, whereas patients with Graves’ disease require antithyroid drugs. Patients present with classical symptoms of thyrotoxicosis and, rarely, with thyroid storm. The deﬁnitive treatment of hyperthyroidism associated with molar preg- nancy is evacuation; however, many patients require β-blockers and antithyroid drugs for control of thyrotoxicosis prior to evacuation. Women with Graves’ disease experience exacerbation of symptoms during the ﬁrst trimester, and there is a gradual improvement during the second and third trimester. Further, 20–30% of patients may not require antithy- roid drugs in the last trimester. However, soon after delivery there may be aggravation of disease due to sudden decline in placental steroids and reactiva- tion of autoimmunity. This is evidenced by the fact that patients with Graves’ disease who are in remission preconceptionally have a higher rate of relapse during post-partum period, as compared to non-pregnant women (84 vs 56%). Fetal thyrotoxicosis manifests as persistent tachycardia (>170 bpm lasting >10 min), intrauterine growth retardation, goiter, congestive cardiac failure, hydrops fetalis, and accelerated bone maturation. Goiter in a fetus commonly results from the use of antithyroid drugs or iodine- containing preparations by the mother. Women who are euthyroid on maintenance doses of antithyroid drugs (5–15 mg carbimazole) can safely proceed for pregnancy. A patient with Graves’ disease who is drug-naïve or toxic on antithyroid drugs or euthyroid on higher doses of antithyroid drugs (>15 mg carbimazole) should be considered for ablative ther- apy prior to conception. This is because of difﬁculties in controlling hyperthy- roidism during pregnancy, risk of fetal thyroid dysfunction due to transplacental passage of antithyroid drugs, and the possibility of resurgence of disease in postpartum period. After radio-ablation, conception should be avoided for the next 6 months for optimizing levothyroxine therapy. Hyperthyroidism can be associated with preterm delivery, preeclampsia, fetal/ neonatal thyrotoxicosis, and increased perinatal and maternal mortality; hence treatment is indicated. The treatment of choice for Graves’ disease during preg- nancy is antithyroid drugs. Therefore, switching over to propylthiouracil in the ﬁrst trimes- ter may not be associated with lesser risk of thionamide embryopathy. Iodized salt should be continued in pregnant women even with Graves’ disease as it is required for fetal thyroid and neural growth and development. Free T4 should be maintained at or just above trimester-speciﬁc upper limit of normal, or if total T4 is opted, then it should be kept one and a half times upper limit of normal. Serum T3 is not useful for monitoring, as attempts to nor- malize serum T3 during pregnancy result in overtreatment with antithyroid drugs and fetal hypothyroidism. Theoretically, propylthiouracil has lesser risk of congenital malformations due to its increased protein binding and lower transplacental transfer. What are the thyroid dysfunction in newborn of a mother with subclinical hypothyroidism?