Thyrotoxicosis and Cardiomyopathy

• Hyperthyroid effects on the cardiovascular system are not the same as hyperadrenergic states
• Direct effects on vascular smooth and cardiac tissue leads to:
1. Decreased SVR
2. Decreased diastolic BP = Decreased afterload
3. Activation of Renin-Angiotensin-Aldosterone = Increased Preload
4. Direct cardiac inotropy + chronotropy
• Ultimately, increased CO (HRxSV) that can lead to HF and dysrhythmias
1. May be catastrophically precipitated by stressors such as sepsis 
• Treatment of Thyroid Storm
1. B-Blockade
2. Thyroid Inhibition
1. Synthesis  -   PTU or Methimazole
2. Release   -   SSKI
3. Periph Conversion (T4 to T3)  -   Hydrocortisone

HIV and PID

• Suspect HIV in any severe febrile illness without a source
• Know emerging demographics - Minority, heterosexual, women
• PID treatment in HIV+ patients has similar approach and outcome as HIV-
1. HIV+ may be more likely to develop TOA
• IUDs are do not predispose to PID after the first 3 weeks post-placement
• Usual culprit : Actinomyces, but treat for GC/CT!

TOA
    - Has same risk factors as PID
        - Multiple sexual partners
        - 15-25 yrs old
        - History of prior PID

2 forms 
    - Tobuovarian complexes (agglutination of pelvic organs +/- bowel)
    - Collection of pus

    - Often begins with DTD, but once abscess forms it is usually polymicrobial

  > Think about when you have suspicion for PID but are acutely ill, failure of treatment with normal therapy; diffuse abdominal pain

  > Imaging = US is 1st choice

Infection

      > 2-7 days post abortion - ascending infection; risk factors include operative intervention, retained POC             advanced gestation

     Retained POC = endometrial stripe >5mm on TVUS

      > Sx - history, fever (though common to not have a fever), abd pain, discharge, vaginal bleeding, tender         uterus, adnexa

      > Antibitoic regimens
            - Outpatient - levaquin, flagyl;
            - Inpatient - vanc, zosyn +/- amp/gent vs vanc and meropenam;
            Remember tetanus

Rh immunization - Rh negative mom, Rh positive fetus - with mixing of maternal and fetal blood; not a lot of great clinical evidence out there so unclear if our Rhogam dosage is correct, unclear how much maternal bleeding is required to have alloimmunization