Ramida Amornsitthiwat, M.D.

งานนำเสนอเรื่อง: "Ramida Amornsitthiwat, M.D."— ใบสำเนางานนำเสนอ:

1 Ramida Amornsitthiwat, M.D.
Biological fluids Ramida Amornsitthiwat, M.D.

2 Biological fluids Cerebrospinal fluid Amniotic fluid Seminal fluid
Saliva Human milk

3 Cerebrospinal fluid (CSF)
brain and spinal cord total volume : mL daily production : mL (20 mL/hr) synthesis : 70% choroid plexus (active transport & ultrafiltration) : 30% ependymal cells subarachnoid space, ventricular system (space between arachnoid & pia mater)

4 CSF circulation lateral ventricles (choroid plexus) foramen of Monro
third ventricle cerebral aqueduct fourth ventricle foramen of Luschka & Magendi basal cisterns & subarachnoid space reabsorption at venous sinus via arachnoid granulations

5 CSF functions physical support of brain protection of brain
chemical stability removes waste products of cerebral metabolism

6 Blood brain barrier (BBB)
physiologic barrier (circulating blood & CSF) - endothelial cell of brain capillaries (tight junction, no intercellular pores) - end-feet of astrocytes (astroglia) Infiltration - fat-soluble drugs (e.g. anesthetic & alcohol) - glucose, urea & creatinine - penicillin & streptomycin - proteins

7 Examination of CSF Lumbar puncture (LP)

8 Examination of CSF Lumbar puncture (LP) Indications
diagnostic - CNS infection eg. meningitis, encephalitis - hemorrhage - malignancy - demyelinating disease treatment - spinal anesthesia - antibiotics - chemotherapy follow up

9 Examination of CSF Lumbar puncture (LP) Contraindications
local infection at lumbar puncture site intracranial mass lesion (brain herniation) large brain abscess brain tumor subdural hematoma intracranial hemorrhage thrombocytopenia

10 Examination of CSF Lumbar puncture (LP) Complications headache
: CSF leakage 2. cerebellar or tentorial herniation :increase intracranial pressure 3. paralysis 4. meningitis 5. accidental puncture of the spinal cord

11 CSF analysis pressure gross appearance microscopic examination
chemical analysis

12 CSF analysis Pressure: 70 – 180 mmH2O Increase intracranial pressure
1. brain edema e.g.cerebral ischemia, meningitis, encephalitis 2. increase CSF volume e.g. hydrocephalus 3. bleeding e.g. intracerebral hemorrhage or subarachnoid hemorrhage 4. mass lesion e.g. brain tumor, brain abscess

13 Increased CSF volume increased CSF production
normal hydrocephalus increased CSF production 2. obstruction of CSF circulation 3. decreased CSF reabsorption

14 CSF analysis 2. Gross appearance: clear / colourless Abnormal findings
cloudy, turbid meningitis WBC > /mm3 bloody traumatic tap subarachnoid hemorrhage intracranial hemorrhage xanthochromia subarachnoid hemorrhage (SAH)

15 Bloody CSF SAH traumatic tap Supernatant (หลังปั่น) xanthochromia
ใส WBC < 1:1000 ~ 1:1000 (peripheral blood) three-tube test สีแดงคงเดิม สีจางลงตามลำดับ red cells lysis oxyhemoglobin (pink) bilirubin (yellow) onset : 2-4 hrs หลังจากเกิด SAH

16 Xanthochromia สาเหตุอื่นๆ 1. jaundice
free and conjugated bilirubin in CSF total plasma bilirubin > 4-6 mg/dL 2. dietary hypercarotenemia 3. CSF protein > 150 mg/dL 4. drug e.g. rifampicin

17 CSF analysis 3. microscopic examination WBC 0-5 cells/mm3
Abnormal findings - leukocytes - neutrophils in bacterial meningitis - lymphocytes in viral meningitis - tumor cells - bacteria, fungi, yeast

18 Chemical analysis of CSF
Protein mg/dL - high protein ( > 65 mg/dL) - permeability of BBB eg. meningitis - traumatic tap, SAH - obstruction of CSF - CNS IgG synthesis - low protein : no significance

19 Chemical analysis of CSF
Glucose - plasma glucose  CSF (active transport & diffusion) - high glucose : hyperglycemia - low glucose (<40 mg/dL or 40% serum glucose) * meningitis – bacterial, TB, fungal * hypoglycemia, SAH, neurosyphilis * CNS leukemia & lymphoma causes 1. abnormal transportation of glucose 2. increased glycolytic activity 3. glucose comsumption of leukocytes and microorganisms 50-80 mg/dL (60-70% or 2/3 of serum glucose)

20 Chemical analysis of CSF
Lactate anaerobic metabolism 10-22 mg/dL CNS hypoxia CSF lactate meningitis cerebral infarction hypotension brain injury bacterial meningitis > viral meningitis

21 Chemical analysis of CSF
LDH (lactate dehydrogenase) - meningitis, leukemia, cerebral ischemia ammonia & glutamine - hepatic encephalopathy - ammonia : toxic to CNS - ammonia + glutamate glutamine IgG - multiple sclerosis, neurosyphylis Tumour markers 1. carcinoembryonic antigen (CEA) 2. -fetoprotein (AFP) 3. human chorionic gonadotropin (hCG)

22 Meningitis causes - bacteria virus tuberculous parasite
fungal e.g.Cryptococcus Brudzinski’s sign Kernig’s sign

23 Meningitis tuberculous (L) 50-400 clear viral bacterial Cryptococcal
50-500 +/- turbid eosinophilic cells glucose (mg/dL) protein (mg/dL) macroscopy meningitis (L>P) tuberculous

24 Amniotic fluid : cushioning the fetus : fetal movement
: promoting muscular/skeletal development : controlling temperature : diagnostic tool for health & maturity of fetus

25 Amniotic fluid early pregnancy - amniotic membrane
late pregnancy - fetal urine (16+ wk.) fetal respiratory tract - desquamated fetal cell Absorbed via fetal swallowing and amniotic membrane maximal volume 1000 mL at gestational age weeks (term pregnancy = weeks) 25

26 Abnormalities of amniotic fluid
1. volume 1.1 oligohydramnios - < 400 mL - renal agenesis, abnormality of urinary tract 1.2 polyhydramnios - > 2000 ml - acute : fetal heart failure, hydrops fetalis - chronic : anencephaly, esophageal atresia 2. color blood, meconium, dark red-brown 26

27 Gross examination of amniotic fluid
color condition เหลืองใส (หรือขุ่นเล็กน้อย) normal เหลืองมาก HDN* เขียว : meconium stain (ขี้เทา) fetal hypoxia แดงคล้ำ fetal death *HDN : hemolytic disease of the newborn (erythroblastosis fetalis) 27

28 Amniocentesis 1. Transabdominal 2. Transcervical 3. Cul de sac
(prenatal diagnosis) 1. Transabdominal 2. Transcervical 3. Cul de sac Complication of amniocentesis 1. Trauma 3. infection 2. Hemorrhage 4. amniotic fluid leakage  abortion %  preterm labour 28

29 Amniotic fluid analysis
cytologic & DNA studies - chromosomal disorders - sex biochemical analysis - alpha 1-fetoprotein (AFP) - phospholipids - bilirubin 29

30 Amniotic fluid analysis

31 Indications for chromosome study
มารดาอายุ > 35 ปี เมื่อถึงวันครบกำหนดคลอด 2. มารดาและ/หรือบิดามีภาวะโครโมโซมผิดปกติ 3. มีบุตรที่มีภาวะโครโมโซมผิดปกติในครรภ์ก่อน 4. มีบุตรพิการแต่กำเนิดโดยไม่ทราบสาเหตุ 5. มีบุตรเสียชีวิตในครรภ์โดยไม่ทราบสาเหตุ 6. บิดามารดาเป็นพาหะของโรคถ่ายทอดทางกรรมพันธุ์แบบลักษณะด้อย 31

32 Amniotic fluid analysis
α 1- fetoprotein (AFP) yolk sac and fetal liver - high level : neural tube defects low level : Down syndrome can be detected in maternal serum 32

33 Amniotic fluid analysis
Phospholipids amphipathic molecule form micelle & lipid bilayer lecithin (dipalmitoylphosphatidylcholine - DPPC) - phosphatidylglycerol (PG), sphingomyelin (S) lung surfactant

34 Roles of Lung surfactant
surfactant decreases surface tension pulmonary compliance alveolar collapse Respiratory distress syndrome (RDS) Fetal lung maturity - L/S ratio phosphatidylglycerol foam stability or shake test L/S < immature L/S intermediate L/S ≥ lung maturity 34

35 Shake test (foam stability test)
Amniotic fluid + 95% ethanol shake 30 sec ดูฟอง ตั้งทิ้งไว้ 15 sec Qualitative test lung surfactant  foam stability 35

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37 ลูกคนแรก Rh +ve เลือดมารดา Rh -ve ลูกคนที่ 2 Rh +ve
Amniotic fluid analysis Isoimmunization : fetal-maternal blood incompatibility (hemolytic disease of the newborn) ลูกคนแรก Rh +ve Ag เลือดมารดา Rh -ve sensitized : ตรวจพบ Rh Ab ในเลือดมารดา ลูกคนที่ 2 Rh +ve Rh Ab ของแม่ผ่านรกมาทำปฏิกิริยากับ Rh +ve ในเลือดของลูก RBC hemolysis bilirubin (scan spectrophotometer ที่ 450 nm) 37

38 Semen , Seminal fluid a suspension of spermatozoa in the seminal plasma 38

39 Semen testis 5% spermatozoa seminal vesicle 60%
สารน้ำเหนียว, pH กลาง-ด่าง, มี fructose ซึ่งเป็นแหล่งพลังงานของ sperm prostate gland 20% คล้ายน้ำนม, pH เป็นกรดอ่อน(~6.5) ผลิต acid phosphatase & proteolytic enzyme (coagulation & liquefaction) epididymis, vas deferens, bulbourethral gland 10-15% สร้าง protein ที่จำเป็นสำหรับ การเคลื่อนที่ของ sperm 39

40 microscopic examination
Semen analysis gross examination microscopic examination Indications ประเมินภาวะมีบุตรยาก (infertility) ประเมินผลของการทำหมันชาย (vasectomy) ประเมินผลประกอบคดีทางนิติเวช (forensic medicine) 40

41 Gross examination of semen
volume : 2-5 mL coagulation process - fibrin-liked precursor (seminal vesicle) - clotting enzyme (prostate) liquefaction process - proteolytic enzyme (prostate) 41

42 Microscopic examination of semen
sperm count normal million/mL oligospermia < 20 million/mL azoospermia : no spermatozoa motility motile spermatozoa % sperm morphology normal morphology % 42

43 Analysis of semen การประเมินผลของการทำหมันชาย
- หลังทำหมัน 6 เดือน ไม่ควรตรวจพบ sperm การตรวจอสุจิประกอบคดีทางนิติเวช 1. sperm cytology - 7 วัน หลังร่วมเพศ 2. acid phosphatase activity - prostate gland - 3 วัน หลังร่วมเพศ - high sensitivity 43

44 Saliva Production Composition 500-1500 mL/day salivary gland
parotid : serous sublingual : mucous > serous submandibular : serous > mucous - autonomic nervous system physiological/pathological condition Composition inorganic compounds : hypotonic fluid organic compounds : uric acid protein compounds : amylase,IgA hormones : catecholamines

45 Biochemical laboratory analysis of saliva
viral and bacterial infections - genome and antibodies detection 2. cancer e.g. c-erb-2 soluble fragment 3. pharmaceutical and drug abuse 4. hormones - cortisol 5. DNA test - biomarker profiling or forensic identification 6. sialochemistry analysis - heavy metal

46 Mumps contagious disease : virus children age 2-12 years
respiratory secretions, saliva fever, headache, painful and swollen parotid gland at the face, neck and jaw complications : orchitis : meningitis : encephalitis

47 Human milk Stage of lactation 1. colostrum (first few days)
- immunologic compound (secretory immunoglobulin A) 2. transitional milk (5 days-2 weeks) - rumped up milk 3. fully mature milk (4-6 weeks)

48 Human milk Composition Nutrition component macronutrient
protein : casien, Haptocorrin (transcobalamin II), α-lactalbumin, whey fat : palmatic acid and oleic acid lactose micronutrient - vitamin : low vitamin K

49 2. Bioactive component 3. Immunologic factors bioactive factors
- bile-salt stimulated lipase - epidermal growth factor - growth factors anti-infective factors secretory immunoglobulin A (sIgA) white blood cells whey proteins (lysozyme and lactoferrin) oligosacccharides

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