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In cases of mixed synergistic infection erectile dysfunction medications in india purchase 20mg levitra jelly with mastercard, appropriate coverage for facultatively aerobic gram-negative rods and obligate anaerobes includes a carbapenem impotence kit generic levitra jelly 20mg on-line, a -lactam/-lactamase inhibitor, or a third- or fourth-generation cephalosporin in combination with metronidazole. Because some of the manifestations of streptococcal necrotizing fasciitis are toxin mediated, clindamycin should be used in conjunction with other antibiotics, because as a protein synthesis inhibitor, it shuts down further production of exotoxins and M-protein production by group A streptococci, a phenomenon known as the Eagle effect. After cultures have been obtained, appropriate antibiotic therapy initiated, and stabilization of the patient has begun, attention should focus on source control. This can include removal of indwelling lines and catheters, with replacement if necessary. In some sources of infection, such as urosepsis, aggressive surgical or percutaneous drainage is not usually indicated; in other cases, such as localized extremity abscess, surgical drainage should occur as soon as the patient has stabilized. When drainage of an intraabdominal or pelvic abscess is necessary, the percutaneous approach is often preferable. In obstetric conditions, evacuation of the uterus by suction curettage (in septic abortion) or delivery of the neonate (in viable gestations) should occur after initiation of antibiotics and stabilization of the patient. Postpartum hysterectomy may be necessary if the patient fails to respond to antibiotics and the uterus is the suspected source. In the critically ill population, hyperglycemia is a common phenomenon attributable to insulin resistance and escalations in glucagon, cortisol, and catecholamine levels, which promote glycogenolysis and gluconeogenesis. Septic patients exhibited an even more impressive 76% reduction in mortality as a result of aggressive euglycemia with insulin therapy. The beneficial effects of tight insulin control were demonstrated in two other small trials. All of these studies reported a much higher incidence of severe hypoglycemia (glucose 40 mg/dL) with intensive insulin therapy. Aggressive euglycemia in the critically ill pregnant patient likely results in excessive rates of hypoglycemia and cannot be recommended. The optimal blood glucose range in critically ill parturients remains to be defined, but it is likely between 140 and 170 mg/dL. Empiric administration of high-dose corticosteroids does not improve survival among unselected septic patients and may worsen outcomes due to secondary infection. Stresses such as pain, fever, anxiety, hypovolemia, and severe illness can stimulate marked increases in cortisol levels. This was also true in two predefined subgroups (those with inadequate versus adequate adrenal reserve) established using the cosyntropin stimulation test. Regardless of the baseline cortisol levels, the hydrocortisone group had faster reversal of shock than other patients (3. For the septic shock patient who remains undelivered, care should be taken in the choice of corticosteroids. Betamethasone and dexamethasone cross the placenta and can improve neonatal outcomes for the premature infant. However, both have been associated with worse neonatal outcomes when administered repeatedly in large doses. The 2012 Surviving Sepsis guidelines outline recommendations regarding additional supportive therapies for severe sepsis. A tidal volume of 6 mL/kg of predicted body weight should be targeted, and the upper limit goal for plateau pressures should be 30 cm H2O or less. Sedation should be minimized, and specific titration endpoints should be targeted. Red blood cell transfusion should occur only when hemoglobin concentration decreases to less than 7. This conservative transfusion strategy applies after tissue hypoperfusion resolves and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute haemorrhage, or ischemic heart disease. Patients with severe sepsis should also receive daily pharmacologic prophylaxis against venous thromboembolism unless contraindicated. Chemical prophylaxis should be combined with mechanical prophylaxis, such as intermittent compression devices. Stress ulcer prophylaxis should be administered as well, with a proton pump inhibitor (rather than an H2 blocker) in patients with bleeding risk factors (coagulopathy, mechanical ventilation for >48 hours, and possibly hypotension).

Contractions and preterm labor are to be expected erectile dysfunction among young adults purchase levitra jelly 20mg otc, particularly in a severely burned pregnant patient erectile dysfunction drug overdose purchase levitra jelly overnight, although the frequency is unknown. Tocolysis should therefore be undertaken cautiously with an appreciation of the hemodynamic effects and other side effects of the drug. Hypovolemic patients may not tolerate -agonists such as terbutaline, because they may already be in a high-output state. Because of the high fetal mortality rates associated with severe burns, delivery may be the most judicious alternative for a viable gestation. Most investigators recommend cesarean section for the usual obstetric indications. Delivery by cesarean section through a burned abdomen 71 Intensive Care Considerations for the Critically Ill Parturient 1209 and vaginal delivery through a burned perineum have been reported. In a review of 38 patients delivered in the perimortem period by cesarean section, the causes included trauma, cardiac abnormalities, embolism, magnesium overdose, sepsis, intracranial hemorrhage, anesthetic complications, eclampsia, and uterine rupture. Perimortem cesarean section is a rarely performed procedure, partly due to the few instances of witnessed maternal cardiac arrest and the lack of understanding of the procedure and its role in the management of this group of patients. Eighty percent of the force generated in the supine position is preserved at this angle. The use of sodium bicarbonate to correct maternal acidosis should be undertaken with caution because of concerns regarding the potential for worsening fetal acidosis. Electrocardioversion can be performed in a pregnant patient; the recommendations are the same as for nonpregnant patients. However, if return of spontaneous circulation does not occur, attention must then be directed to evacuation of the uterus by cesarean section. The purpose of advocating cesarean section in the setting of maternal cardiac arrest is to improve the likelihood of an intact neonatal outcome and simultaneously improve maternal resuscitative efforts. Maternal neurologic injury could be avoided if cerebral perfusion improved by 6 minutes, the time at which cerebral injury occurs after cessation of blood flow. They then reviewed the literature and reported neonatal outcomes at various time intervals after delivery. From these data, it is clear that delivery within 5 minutes of arrest was most likely to result in good neonatal outcomes. In this series, 79% (30 of 38) delivered live infants (including three sets of twins and one set of triplets). Data were available regarding the arrest-todelivery interval for 25 infants and are presented in Table 71-15. Similar to the data from earlier series, prolonging the arrest-to-delivery interval decreased the likelihood of intact survival, although apparently normal neonates were delivered even in the group requiring more than 15 minutes. In a Danish population study reviewing perimortem cesarean section between 1993 and 2008, none of the 12 perimortem cesarean sections performed was accomplished in the recommended 5-minute window after arrest. The overall maternal survival rate was 15% (8 of 55) for all patients after maternal arrest and 17% (2 of 12) for those who were delivered by perimortem cesarean. Emergency skills training increased the likelihood that a perimortem cesarean would be performed. In the series by Katz and coworkers, 20 (59%) of 34 cases provided information regarding maternal hemodynamic status and indicated a beneficial effect on maternal resuscitation efforts after perimortem cesarean. For the perimortem cesarean group of patients, the mortality rate was 83% (10 of 12), compared with 67% for the group that remained undelivered. Three appeared to have no adverse sequelae, one had evidence of neurologic impairment, and one became lost to follow-up. Six of the 43 patients who suffered cardiac arrest and did not undergo perimortem cesarean survived the event. Follow-up information on the outcomes for this group of patients was not reported. Relocating the patient from a labor room to an operating room significantly impacts the ability to achieve delivery within the recommended 5-minute window in a simulated environment. Fifty-seven percent of cases were accomplished in 5 minutes if the patient was not relocated, compared with 14% if relocation took place. This demonstrates the challenges inherent in performing a timely delivery under these circumstances.

Amiodarone is the most effective antidysrhythmic drug for prevention of paroxysms of atrial fibrillation in these patients how to treat erectile dysfunction australian doctor cheap 20 mg levitra jelly overnight delivery. Long-term anticoagulation is indicated in those with recurrent or chronic atrial fibrillation impotence kegel purchase generic levitra jelly online. Surgical reduction of the outflow gradient is usually achieved by removing a small amount of cardiac muscle from the ventricular septum (septal myomectomy). Similar results can be obtained by percutaneous cardiac catheterization and selective alcohol injection into the septal perforator arteries. If patients remain symptomatic despite various therapies, a prosthetic mitral valve can be inserted in an attempt to counteract the systolic anterior motion of the mitral leaflet. However, the subset of patients at high risk of sudden death (family history of sudden death or history of malignant ventricular dysrhythmias) have a mortality rate of 5% per year. Patients already diagnosed with this disease should undergo an updated cardiac evaluation before elective surgery. Patients taking -blockers or calcium channel blockers should continue these medications throughout the perioperative period. Every patient should be asked preoperatively about any possible cardiac symptoms or a family history of cardiac disease or sudden death. Induction of anesthesia with an intravenous drug is acceptable, but the importance of avoiding sudden decreases in systemic vascular resistance and increases in heart rate and contractility must be kept in mind. Administration of a volatile anesthetic or -adrenergic antagonist before direct laryngoscopy can blunt the sympathetic response typically evoked by tracheal intubation. To help avoid this, smaller tidal volumes and higher respiratory rates should be used and positive end-expiratory pressure should be avoided. The surgeon should be advised about this possibility, and the abdomen should be insufflated slowly and at pressures not exceeding 15 mm Hg. The increased heart rate that may accompany administration of pancuronium and the histamine release associated with other neuromuscular blockers should be avoided. Anesthesia should be maintained with drugs that produce mild depression of myocardial contractility and have minimal effects on preload and afterload. Hypotension that occurs in response to a decrease in preload or afterload should be treated with an -adrenergic agonist such as phenylephrine. Prompt replacement of blood loss and titration of intravenous fluids is important for maintaining preload and blood pressure. However, because of diastolic dysfunction, aggressive fluid replacement may result in pulmonary edema. Maintenance of normal sinus rhythm is very important, because adequate left ventricular filling is dependent on left atrial contraction. Patients who develop intraoperative supraventricular tachydysrhythmias should undergo immediate pharmacologic or electrical cardioversion. Should hypotension unresponsive to fluid administration occur as a result of regional anesthesia, phenylephrine should be used to increase afterload. Oxytocin must be administered carefully because of its vasodilating properties and compensatory tachycardia, and because of the abrupt inflow of large amounts of blood into the central circulation as a consequence of uterine contraction. Diuretics, digoxin, and nitrates cannot be used to treat pulmonary edema in this setting. All factors that stimulate sympathetic activity, such as pain, shivering, anxiety, hypoxia, and hypercarbia, should be eliminated. As in the operating room, maintenance of euvolemia and prompt treatment of hypotension are crucial. The etiology of dilated cardiomyopathy is unknown, but it may be genetic or associated with infection such as coxsackievirus B infection. There is a familial transmission pattern in approximately 30% of cases, usually autosomal dominant. Many types of secondary cardiomyopathies have the features of dilated cardiomyopathy. Dilated cardiomyopathy is the most common type of cardiomyopathy, the third most common cause of heart failure, and the most common indication for cardiac transplantation. Ventricular dilation may be so marked that functional mitral and/or tricuspid regurgitation occurs. Supraventricular and ventricular dysrhythmias, conduction system abnormalities, and sudden death are common. Systemic embolization is also common as a result of the formation of mural thrombi in dilated and hypokinetic cardiac chambers.

There are no reports of the use of calcium channel blockers for tocolysis among patients with asthma impotence newsletter purchase levitra jelly 20mg otc, although an association with bronchospasm has not been observed with wide clinical use erectile dysfunction nyc buy levitra jelly 20mg on-line. Lumbar anesthesia has the benefit of reducing oxygen consumption and minute ventilation during labor. Additional conditions that cause a restrictive ventilatory defect include pleural and chest wall diseases and extrathoracic conditions such as obesity, peritonitis, and ascites. One study presented data on nine pregnant women with interstitial and restrictive lung disease who were prospectively managed. Three of the gravidas had severe disease characterized by a vital capacity of no more than 1. All other patients were delivered at or beyond 36 weeks with no adverse intrapartum or postpartum complications. However, exercise intolerance is common, and these patients may require early oxygen supplementations. During the postpartum period, no relapse occurred in 15 patients; however, progression of the disease continued in three women. Another retrospective study assessed 15 pregnancies complicated by maternal sarcoidosis over a 10-year period. In this group, factors indicating a poor prognosis included parenchymal lesions identified on the chest radiograph, advanced radiographic staging, advanced maternal age, low inflammatory activity, requirement for drugs other than steroids, and the presence of extrapulmonary sarcoidosis. The overall cesarean section rate was 40%, and 4 (27%) of 15 infants weighed less than 2500 g. One explanation for the commonly observed improvement in sarcoidosis may be the increased concentration of circulating corticosteroids during pregnancy. However, because sarcoidosis improves spontaneously in many nonpregnant patients, the improvement may be coincident with pregnancy. Maycock and associates153 reported 16 pregnancies in 10 patients with sarcoidosis. Eight of these patients showed improvement in at least some of the manifestations of sarcoidosis during the antepartum period. A recurrence of the abnormal findings was observed in the postpartum period within several months after delivery in approximately half of the patients. Another study examined 17 pregnancies in 10 patients and concluded that pregnancy had no consistent effect on the course of the disease. When the lesions on the chest radiograph had resolved before pregnancy, radiographs remained normal throughout gestation. In women with radiographic changes before pregnancy, resolution continued throughout the prenatal period. Patients with inactive fibrotic residual disease had stable chest radiographs, and those with active disease tended to have partial or complete resolution of those changes during pregnancy. However, most patients in the latter group experienced exacerbation of the disease within 3 to 6 months after delivery. Patients with pulmonary hypertension complicating restrictive lung disease may have a mortality rate as high as 50% during gestation. These patients need close monitoring during the labor, delivery, and postpartum periods. Invasive monitoring with a pulmonary artery catheter may be indicated to optimize cardiorespiratory function. Gravidas with restrictive lung disease, including pulmonary sarcoidosis, may benefit from early institution of steroid therapy for evidence of worsening pulmonary status. Individuals with evidence of severe disease need close monitoring and may require supplemental oxygen therapy during gestation. During labor, consideration should be given to the early use of epidural anesthesia if it is not contraindicated. The early institution of pain management in this population can minimize pain, decrease the sympathetic response, and decrease oxygen consumption during labor and delivery. The use of general anesthesia should be avoided, if possible, because these patients may develop pulmonary complications after general anesthesia, including pneumonia and difficulty weaning from the ventilator. Close fetal surveillance throughout gestation is indicated because impaired oxygenation may lead to impaired fetal growth and the development of fetal heart rate abnormalities during labor and delivery. An additional consideration is the need to counsel all women with restrictive lung disease about the potential for continued impairment of their respiratory status during pregnancy, particularly if their respiratory status is deteriorating when they conceive.

Surgical decortication to remove thick fibrous pleura is technically difficult and is considered only if the restrictive lung disease is symptomatic impotence emedicine discount 20mg levitra jelly with amex. Thus erectile dysfunction treatment saudi arabia purchase genuine levitra jelly on line, quadriplegic patients who have preserved phrenic nerve and diaphragmatic function are unlikely to develop respiratory failure in the absence of pneumonia or administration of central nervous system depressant drugs. In the supine position, patients with diaphragmatic paralysis may develop a ventilatory pattern similar to that seen with a flail chest (abdominal contents push the diaphragm into the chest). In the upright posture these patients experience a significant increase in vital capacity and improved oxygenation and ventilation. Most cases of unilateral diaphragmatic paralysis are the result of neoplastic invasion of the phrenic nerve. In the absence of associated pleuropulmonary disease, most adult patients with unilateral diaphragmatic paralysis remain asymptomatic, and the defect is detected as an incidental finding on chest radiography. In contrast, infants are more dependent on bilateral diaphragmatic function for adequate respiratory function. In these patients and in symptomatic adults, plication of the hemidiaphragm may be necessary to prevent flail motion of the thoracic cage. Lung volumes are decreased, the alveolararterial oxygen difference increases, and respiratory frequency increases. These changes may be caused by irritation of the diaphragm, which causes reflex inhibition of phrenic nerve activity. As a result of postoperative diaphragmatic dysfunction, atelectasis and arterial hypoxemia may occur. The result is a progressive increase in the amount of air trapped under increasing pressure (tension). Tension pneumothorax occurs in fewer than 2% of patients experiencing an idiopathic spontaneous pneumothorax, but it is a common manifestation of rib fractures, insertion of central lines, and barotrauma in patients undergoing mechanical ventilation. Immediate evacuation of gas through a needle or a small-bore catheter placed into the second anterior intercostal space may be lifesaving. Physical findings are often subtle, which emphasizes the importance of considering this diagnosis whenever dyspnea and chest pain occur acutely. In patients with a large pneumothorax, the findings on physical examination of the affected side may include decreased chest wall movement, hyperresonance to percussion, and decreased or absent breath sounds. Treatment of a symptomatic pneumothorax requires evacuation of air from the pleural space by aspiration through a small-bore plastic catheter or placement of a chest tube. Aspiration of a pneumothorax followed by catheter removal is successful in 70% of patients with a small to moderate-sized primary spontaneous pneumothorax. When the pneumothorax is small (<15% of the volume of the hemithorax) and symptoms are absent, observation may suffice. Complications of chest tube drainage include pain, pleural infection, hemorrhage, and pulmonary edema related to lung reexpansion. Recurrent pneumothoraces may require surgical intervention including chemical pleurodesis. Preoperative evaluation of patients with mediastinal tumors includes chest radiography, measurement of a flow-volume loop, chest imaging studies, and clinical evaluation for evidence of tracheobronchial compression. Flexible fiberoptic bronchoscopy under topical anesthesia may also be useful for evaluating airway obstruction. Interestingly, the severity of preoperative pulmonary symptoms bears no relationship to the degree of respiratory compromise that can be encountered during anesthesia. Indeed, a number of asymptomatic patients have developed unexpected airway obstruction during anesthesia. In symptomatic patients requiring a diagnostic tissue biopsy, a local anesthetic technique, if feasible, is best. Patients with mediastinal tumors may be asymptomatic while awake yet develop airway obstruction during anesthesia in the supine position. During anesthesia, the tumor may increase in size because of venous engorgement, and its position may shift somewhat.

The only medical treatment that may influence the outcome of Bell palsy is steroid therapy circumcision causes erectile dysfunction purchase 20 mg levitra jelly fast delivery, based on several randomized controlled trials erectile dysfunction treatment charlotte nc purchase genuine levitra jelly on-line. Polyneuropathies Although several early reports noted the occasional occurrence of a polyneuropathy during pregnancy, there does not appear to be any specific polyneuritis of pregnancy. Any type of polyneuropathy, such as that caused by diabetes mellitus, may develop during the gestational period. Discussion here is limited to those most likely to manifest clinically or to pose a management problem during pregnancy. Signs of peripheral nerve involvement may be found in patients with hyperemesis gravidarum who have Wernicke encephalopathy. In the limbs, numbness, paresthesias, and dysesthesias are accompanied by cutaneous sensory loss, depressed tendon reflexes, and distal weakness. Retrobulbar neuropathy may also occur, and tachycardia, postural hypotension, exertional dyspnea, and sphincter disturbances are sometimes conspicuous. The features of Korsakoff psychosis, which consists of impaired memory and an inability to acquire new information, sometimes accompanied by confabulation, may also be conjoined. The diagnosis of Wernicke encephalopathy is confirmed by the finding of a marked reduction in blood transketolase activity and a marked thiamine pyrophosphate effect. Treatment consists of thiamine (500 mg), which is given intravenously three times daily and then once daily intravenously or intramuscularly for several days, followed by 100 mg orally until a satisfactory dietary intake is ensured. In other instances, a severe polyneuropathy may develop without an accompanying encephalopathy, presumably in relation to a nutritional deficiency, although the specific factors responsible for the peripheral nerve involvement are not known. Patients may complain about pain, paresthesias, and dysesthesias in the extremities; limb weakness; or ataxia. There may be accompanying cardiac involvement, with tachycardia, exertional dyspnea, and heart failure. Treatment consists of a balanced diet and supplements of vitamins, especially B vitamins. Vitamin B12 deficiency may lead to maternal polyneuropathy and other neurologic abnormalities and can affect the fetus and neonate. In many such instances, the neuropathy follows clinical or subclinical infection with Campylobacter jejuni. It can pose an especially difficult management problem when it occurs during pregnancy. The main complaint is of weakness that varies widely in severity in different patients, is often more marked proximally than distally, and is often symmetric in distribution. It usually begins in the legs, frequently comes to involve the arms, and often affects one side or both sides of the face. Weakness may progress to total paralysis and may be life-threatening if the muscles of respiration or deglutition are involved. Autonomic dysfunction may manifest with tachycardia, cardiac irregularities, hypotension or hypertension, facial flushing, disturbances of sweating, disturbed pulmonary function, and other signs and symptoms. Examination of the cerebrospinal fluid reveals characteristic changes: the protein content is significantly increased, but the cell content is normal. Measurement of motor and sensory conduction velocity in the peripheral nerves may reveal marked slowing, but the chronology of this reduction does not necessarily parallel that of the clinical disorder. In some patients, the conduction velocity remains normal, presumably because disease is restricted to the nerve roots or proximal segments of the nerves. Most patients eventually make a good recovery, but it may take many months, and some patients have persistent disability. Improvement in neurologic status may occur before delivery and is not necessarily delayed until the infant is born. In addition to supportive care, with attention directed at the prevention of complications such as respiratory failure and vascular collapse, plasmapheresis or treatment with intravenous immunoglobulins hastens and improves the ultimate degree of recovery in severely affected patients. Although experience with such approaches during pregnancy is limited, both have been used safely in pregnant patients and treatment should probably not be withheld.

Herold M erectile dysfunction yoga youtube buy generic levitra jelly canada, Schnohr S erectile dysfunction treatment philippines buy levitra jelly pills in toronto, Bittrich H: Efficacy and safety of combined rituximab chemotherapy during pregnancy, J Clin Oncol 19:3439, 2001. Adaptations in normal pregnancy and alterations that occur in women with preexisting or newonset kidney disease during pregnancy are the subject of Chapter 7. Although the outcomes for pregnant women with kidney disease and their offspring have improved, several conditions can lead to worsening kidney disease and, at times, kidney disease requiring dialysis.

Whereas excess circulating thyroid hormones cause lid retraction and lid lag impotence what does it mean best 20mg levitra jelly, proptosis and external ocular muscle palsies reflect the infiltrative ophthalmopathy of Graves disease erectile dysfunction how young levitra jelly 20 mg mastercard. If untreated or treated inadequately, women may have more complications during pregnancy and delivery. Very mild cases of hyperthyroidism, with adequate weight gain and appropriate obstetric progress, may be followed carefully, but moderate or severe cases must be treated. However, weight loss, tachycardia greater than 100 beats/min, and diffuse goiter are features that may suggest hyperthyroidism. Graves ophthalmopathy can be helpful but does not necessarily indicate active thyrotoxicosis. The goal of therapy is to control the hyperthyroidism without causing fetal or neonatal hypothyroidism. After the patient is euthyroid (reflected by monthly free T4 and free T3 values), the dose of antithyroid drugs should be tapered. It has been suggested that a change from stimulatory to blocking antibody activity may contribute to this remission. The alternative thionamide can be used, although cross-sensitivity occurs in 50% of patients. All patients experiencing fever or unexpected sore throat on therapy should discontinue the drug and have white blood cell count monitoring. Agranulocytosis is a contraindication to further thionamide therapy; the blood count gradually improves over days or weeks. The risks of untreated hyperthyroidism need to be considered in relation to the risk of antithyroid medications. The risks appear to correlate with the control and severity of the hyperthyroidism. Similarly, prematurity was more common in the hyperthyroid group; the odds ratio was 2. If needed, cordocentesis may be performed and fetal thyroid function determined; reference ranges have been reported. Methimazole also does not appear to affect subsequent somatic or intellectual growth in children exposed to it during lactation. In patients who are in remission, the postpartum period of a subsequent pregnancy is significantly associated with relapse of Graves disease compared with those without a subsequent pregnancy. Propranolol is commonly used in doses of 20 to 40 mg two or three times daily, and it inhibits T4 to T3 conversion. Alternatively, other -blockers may be used (except atenolol, which is category D),1 and in an emergency, esmolol, an ultrashort-acting, cardioselective, intravenous -blocker, has been used successfully. Iodides Iodides decrease circulating T4 and T3 levels by up to 50% within 10 days by acutely inhibiting the release of stored hormone. Sodium ipodate, a radiographic contrast agent, is an alternative that has the added benefit of inhibiting conversion of T4 to T3. Because iodides cross the placenta readily, they should be used for no longer than 2 weeks, or fetal goiter can result. Inadvertent use of iodides also follows use of Betadine cleansing solutions, iodine-containing bronchodilators, and the drug amiodarone. Surgery is best performed in the second trimester, although it can be done in the first or third trimester. The risks are those of anesthesia, hypoparathyroidism, and recurrent laryngeal nerve paralysis. Thyroid Storm Therapy Thyroid storm is a life-threatening exacerbation of thyrotoxicosis. Criteria for its diagnosis have been introduced,106 and the classic findings are various degrees of thermoregulatory dysfunction, central nervous system effects. Although it rarely occurs in pregnancy, it may be precipitated by labor and delivery, cesarean section, infection, or preeclampsia.