<胎兒心律不整 - bradycardia>

才讀完台兒通訊上期的雙月刊，門診就來了一個意外發現有房室傳導阻斷寶寶。
在診間聽心跳的時候，聽半天覺得心跳怎麼這麼慢? 到處都再確定一下又跟媽媽的脈搏相比不同，所以應該也不是聽到媽媽的動脈血流聲，因此帶她去超音波室一照，發現果不其然胎兒的心跳量起來只有70-80下。
立馬安排了比較詳細的心臟超音波，還有抽血來做更進一步的檢查。

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寶寶的心跳正常來說是在110-160下/分鐘之間，超過160下是心搏過快，太低則是心搏過慢。
心律不整是一個大課題，今天先從 #心博過慢這個族群來講起。

完整內容請看部落格文章
https://drjessicakang.blogspot.com/2021/07/blog-post.html
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胎兒心搏過緩要考慮幾個鑑別診斷:
1. 竇性心搏過慢 Sinus bradycardia
(Transient, fetal distress, sinus node dysfunction, Long QT syndrome...)
2. 緩慢性的心律不整 Bradyarrhythmia -> 房室傳導阻斷 AV block

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1. #竇性心搏過慢

表示胎兒心跳是規則的慢，並不是心房心室的傳導出問題，一個A對一個V。

(1) 暫時性的/胎兒窘迫:
待產時候常見的因為胎頭壓迫所造成的心跳過慢，還有心跳一去不復返的胎兒窘迫。
要考慮的可能是超音波做太久探頭壓迫的影響，或是注意媽媽有沒有低體溫的症狀?
如果以上都沒有，但是心跳還是很慢，就要認真考慮是不是其他的問題了。

(2) 竇房結異常:
竇房結出現問題，就會影響到心律，有些結構上的問題可能會影響到竇房結的位置，像是heterotaxy(異位症)，interrupted IVC，或是單一心室的結構。

(3) Long QT syndrome:
如果心臟結構沒有問題，也排除了第二點的房室傳導阻斷，就要考慮是否為long QT syndrome (我對這個疾病的認識要遙想當年在中榮心臟內科當intern被電的時期阿)
但是Long QT這個疾病也通常只能在出生之後用心電圖來確認。

2. #房室傳導阻斷
大概1/15000-20000，大約40%合併心臟結構問題，其他60%若無心臟結構問題，要考慮跟免疫相關(特別是anti-Ro/SSA or anti-La/SSB抗體)

再來就是難到爆的分類 (沒錯就是跟以前CV學的Mobitz type 1漸行漸遠甚麼碗糕的)
基本上分類和大人一模一樣 (這樣是可以不用介紹的意思嗎??)
要量測PR interval還有對照A-V的比例 (認真覺得這期台兒通訊錄介紹的很淺顯易懂而且是中文版，有興趣的人可以去參考看看)

(#詳細說明請看部落格文章)
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***如果是懷疑AV block的胎兒，建議媽媽要抽anti-Ro/SSA, anti-La/SSB抗體，來確認免疫部分有沒有問題。

對於確定有anti-Ro/SSA或是anti-La/SSB抗體的媽媽，以前的印象總是要使用類固醇 (fluorinated corticosteroids)，像是betamethasone or dexamethasone來治療，但是最近有些文獻指出，使用類固醇治療與否對於胎兒預後或是新生兒的預後其實沒有顯著的差別。要加快胎兒心跳，也有人使用salbutamol, b-agonist來治療，但是都沒有定論；另外也有使用IVIG的例子。

對於大家最常使用的 #類固醇，文獻中主要提到有幾點需要注意:

1. #影響胎兒預後的因子: 發現時間點<20週，ventricular rate<50 bpm，胎兒水腫，左心室功能受影響 ->預後差
2. 使用類固醇，主要對於"#預防"胎兒變成最嚴重的3度房室傳導阻斷有用；但是對於已經是完全房室傳導阻斷的胎兒，效用就沒有那麼好
3. 如果出現胎兒水腫，使用類固醇有時候可以 #改善水腫嚴重程度
4. 長期使用類固醇，對於胎兒還是會有一些影響，如 #羊水過少，#胎兒生長遲滯等，因此要衡量一下利弊
5. anti-Ro/SSA, anti-La/SSB抗體陽性的個案，AVBII沒有辦法自發性地回復到正常，但是如果有使用類固醇，就有機會會回復

參考資料:
Michael et al. Eur J Obstet Gynecol Reprod Biol X. 2019 Jun 16;4:100072
Eliasson et al. Circulation 2011 Nov 1;124(18):1919-26

#胎兒異常
#胎兒心律不整
#產前診斷
#產前超音波

(English writing below)

上星期天，我到一間小花圃做春節直播。

以我的慣例，我如果用到店家的地方，我都會買些東西，不佔他人做生意的便宜。

那天開直播前，本想通知店員一聲，但因為急著在一個時間點前結束，忘得一乾二淨，就有勞我師兄去物色購買適合的盆景。

當時有三位員工 - 兩位華族女子，一位異族外勞男子。

開播到一半時，男員工看到我先生的手機正播映著我的直播。

「哇！這是現場直播嗎？」他很興奮地問我先生，「在哪裡可以看？」

「你可以在臉書看。」

男員工二話不說，拿出手機，開啟臉書應用程序，請我先生為他找出我的臉書。先生輸入我的名字後，接下來就更好笑了。

我當時毫不知情，因為專注在直播。

結束後，我翻看按讚名單時，還想著怎麼會有異族朋友的名字。後來，先生才告訴我事情的來龍去脈。

昨天在剪輯直播，想這星期上傳到Youtube時，才發現那位男員工還向我鏡頭揮手，並展示播放著我直播的手機螢幕。😂

雖然我全程都說著華語，但想必他應該或多或少都聽得懂吧！

這畫面非常有趣，因為幾天前，一位女讀者來訊詢問我批八字的收費。（我服務的收費都列在：www.qianyu.sg/consultations 有中文網頁功能）

這女讀者說，我影片裡的資訊非常準確及珍貴。

我感謝她告訴我，因為我沒有印象在臉書互動裡看過她的名字。

她說她害羞。

這讓我想起另一位女客人，也曾說過類似的話。她說她一向很低調，所以雖然獲益匪淺，但從沒想過要按讚。

我問她：

萬一我寫了那麼多，卻得不到觀眾按讚的肯定，以致我放棄寫作與拍片呢？

她沒回答我。

我笑說，我雖不會因此而放棄，因為我曾經發過願，我也會用我的一生去履行我的發願。

但是，只拿不給，非君子所為，而是自私自利。 我也是人，自然也會需要認同感，尤其是寫的又是一些較另類的課題。

給予鼓勵是一種善行，也是一種感謝，無論是通過按讚、留言、分享，或告訴我。

直接與我貼文互動的好處是有時，可以利益其他比我們更需要這訊息的人。

打從我在去年六月底每星期更新Youtube影片後，我收到的詢問也多了。這些詢問當中，好一些是因為他們的臉書朋友分享了我的影片，而認識我。

他們的臉書朋友並不知道他們來找我服務。

畢竟，我們不會向全世界公佈我們的貼身問題。很多時候，向一個陌生人傾述你的問題，比向朋友訴苦還有用，因為那位陌生人有解決你問題的能力。

我在網路寫作已有三年半的時間，看過數百人。表面上看來是我在幫助人，但如大聖佛陀所言，眾生讓我們實踐自己的修行，幫助我們開悟成佛的人。

這是個互相利益的循環。

見的人越多，我越覺得娑婆世界如浮雲，終究沒有任何人事物是自己的。

寫作拍片越多，自己的思維與志向越明確。

我看到到因果的可怕，不想要我客人那般的命運，因此我更加謹言慎行。我親眼目睹貪、嗔、痴如何能毀掉一個人的人生，所以我打開自己的心房，學習把大愛放送出去，放下不利益他人的固執想法。

因此，感謝妳、你、您幫助我成為一個更好的人，幫我找到我的人生目標。這輩子，我從來沒有做一件事那麼開心過，我也想要一生就這樣做下去。

希望我也能幫助到你，盼你也能幫到別人。

___________________________

So last Sunday, I went to a plant stall to do a CNY Live.

As per my usual practice, I would always buy something from the shop if I use its premises. I don’t take advantage of other people’s businesses.

That day, I wanted to preempt the plant stall staff but in my haste to start my Live, I plain forgot about it. So the husband went about looking for a plant to buy on my behalf.

There were about three staff - two ladies and the gentleman standing behind me in this photo.

Halfway through my Live, the male staff saw the handphone screen of the Husband’s.

“Wah! It’s Live ah?” He excitedly asked the husband. “How to see?!”

“You can see on Facebook!”

The staff whipped out his mobile phone and opened the Facebook app. Then the husband typed in my profile name and what followed next was comical.

I wasn’t aware as I was very focused on presenting to my Live audience.

After the Live ended, I looked through the list of Likes to see who engaged with my video.

And I was wondering why there were some foreign names.

Then the husband told me what transpired.

Yesterday while editing the Live for my Youtube upload this week, I realised at one point in time, the staff also waved to my camera and flashed his handphone screen of my Live. 😂

I bet he somewhat understood what I said, despite it being in Mandarin.

It was an interesting moment because few days ago, a lady PM me to inquire about my Bazi consultation fee. (It’s all listed at www.qianyu.sg/consultations btw)

She told me the information in my videos were accurate and valuable.

I thanked her for telling me because I had never seen her name appeared in my engagement list.

She told me she was shy.

This reminded me of a Bazi client who told me the same thing. That client said she had always been low profile, so she did not think to Like my posts even though she benefitted from it.

I told the client:

But what if I stopped writing and filming because I received no or little affirmation from the audience?

She didn’t answered me.

I laughed and said I would not stop because I had made an aspiration in the past. I had made it my lifetime goal to keep my words.

But to be only taking and not giving is always selfish. I am human. And humans always need to feel belonged in one way or another. Even more so when I am writing about unorthodox topics.

Giving encouragement is a form of kindness and showing appreciation, be it through post engagements or telling me now.

The good thing about direct post engagement is that it benefits others, who may need the message more than us.

Since I started weekly uploads to YouTube in June, a lot more queries come in every month. A number of them know me, due to their FB friends sharing my videos on their timeline.

Thing is, their FB friend does not have a clue that they watched my video and came to seek my service.

We don’t go around telling the whole world our problems, you see.

Sometimes, it’s easier to tell a stranger who has the solutions, than a friend who can only tell you to think about happier things.

I have been posting online for 3.5 years and have met hundreds of people. Perhaps to you, it seems that I am helping people.

But like what Buddha says, the sentient beings are here to help us actualise our spiritual practice, to attain enlightenment and Buddhahood.

It is a reciprocal cycle. The more people I see, the more I realise how transient this Samsara world is. The more I write and film, the clearer I am in my thinking and aspirations.

I don't wish to have the kind of destinies I deal with, so I am more careful in my doings and thoughts. I see first-hand how greed, ignorance and anger can kill people, so I have opened up my heart to give out more love and let go of stubborn beliefs that benefit no one.

So thank you to you, you and you for helping me to be a better person and giving me a holy purpose in this life. I have never been happier in my entire lifetime and I want to do this for as long as I live.

I hope I can do the same for you, so that you will do the same for others too.

我老婆在台北市新樂園藝術空間辦個展！這部影片內容是她給大家看些作品和介紹展覽的主題。開幕茶會時我要表演！歡迎大家來跟我們玩！My wife is having a solo exhibition in Taipei at SLY art space next November. In this video she is talking in Chinese about some of her paintings and introducing the theme of the exhibition. I'll be playing at the opening! You are all welcome to come and join us! ;)

風夜狂想曲 Rhapsody on a Windy Night
Marina Burana solo exhibition 明蓮花個展
2018.11.03 － 2018.11.25
Opening 開幕茶會：11.03 (六) 17:00
Venue 展覽地點：新樂園藝術空間 SLY art space
Address 地址：台北市中山區中山北路二段11巷15-2號
No. 15-2, Lane 11, Section 2, Zhong Shan N. Rd., Zhongshan District, Taipei, Taiwan.

https://www.facebook.com/marinaburana/videos/266696694051263/

聽得懂中文：看影片！
This video is in Chinese. For English: read below! :)
Este video está en chino. Si de verdad es muy "chino básico": acá más abajo pueden leer en español! ;)
*
Hello everyone! This little video is in Chinese. It's an invitation to my exhibition next November. In it, I talk a little bit about the paintings and this exhibition in particular. “Rhapsody on a Windy Night” is the title of a poem by T.S. Eliot. I chose this title as the name of my exhibition because I was inspired by this piece to paint this series of paintings. The poem talks about a person wandering through the night, lost in thought, a mere witness and also part of the world around him. It describes a struggle between the most transient of things, memory, and the physicality of existence, the material world. I translated this struggle into this series of paintings all dealing with being underwater as an analogy of being trapped in our memories. Their common thread is the flow of changing color, the intermingling of shapes and movement, just like memory, which "throws up high and dry a crowd of twisted things". This exhibition is very dear to me. The opening will be special since my husband, who is a musician, will perform for us and this is the third exhibition my baby boy will be attending (he attended the first one when in the womb). Also, I will make chocolate chip cookies! For me, every exhibition is a communal activity, an excuse to be together, to create bonds...so please come join us and let's have fun together!
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Hola a todos! Este video está en chino. Es una invitación a mi exhibición de noviembre. En él hablo un poco de las pinturas y de la exhibición en sí. "Rapsodia de una noche de viento" es el título de un poema de T.S. Eliot que fue la fuente de inspiración para hacer estas pinturas. En el poema se presenta a una persona que deambula por la noche, perdida en sus pensamientos, un mero testigo de lo que ocurre a su alrededor y, a la vez, parte fundamental del entramado del mundo. El poema describe una lucha entre la memoria -condenada a escurrirse, transformarse, desaparecer- y lo físico de la existencia, el mundo material. Mi trabajo personal fue traducir esa lucha en esta serie de pinturas que tratan el tema de la vida, el movimiento bajo el agua como una analogía de estar atrapado en la memoria. El denominador común es el fluir del color, el entrelazado de formas y de movimiento, como la memoria, que "arroja y deja en seco una multitud de cosas retorcidas". Esta es una exhibición muy querida para mí. Mi marido va a tocar el piano en la apertura y mi bebito de 9 meses estará allí (esta es su tercera exhibición, a la primera asistió desde la panza). Va a ser algo muy familiar, muy cálido; hasta haré galletitas con chips de chocolate para todos! Para mí, cada exhibición es una forma de crear comunidad, una excusa para generar lazos humanos, así que los que estén en Taipei, bienvenidísimos a jugar un rato con nosotros!
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風夜狂想曲 Rhapsody on a Windy Night
Marina Burana solo exhibition 明蓮花個展
2018.11.03 － 2018.11.25
Opening 茶會：11.03 (六) 17:00
Venue 展覽地點：新樂園藝術空間 SLY art space
Address 地址：台北市中山區中山北路二段11巷15-2號
No. 15-2, Lane 11, Section 2, Zhong Shan N. Rd., Zhongshan District, Taipei, Taiwan.