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From these the terminal spiral and straight arterioles of the endometrium are derived. There are several causes, though often it may be difficult to elucidate the cause, and the treatment becomes empirical. The volumes may exceed several litres, leading to the risk of local anaesthetic toxicity and fluid overload. Frequency of micturition is a normal symptom of early pregnancy and develops again during the last few weeks when the presenting part enters the pelvis. This allows Gardnerella, aerobic and anaerobic organisms to grow and produce typical discharge with fishy odour. Depletes postganglionic adrenergic neurones of noradrenaline by irreversibly preventing its reuptake from axoplasm into storage vesicles. Puberty sets in earlier in moderately obese girls and is delayed in malnourished girl. The best time to do Pap smear is around ovulation, but any other time can also do. Rapid sudden shutdown may result in the liquid coolant of the magnet (cryogen; usually helium in modern devices) boiling off and flooding the immediate area if not properly vented (quenching). Bimanual pelvic examination will reveal an obvious gynaecological cause for infertility. Some couples seem to prefer this method and make no complaints of suffering from strain or anxiety. Unsaturated fatty acids containing 20 carbon atoms and a five-membered carbon ring (cyclopentane ring) at one end. If hypokalaemia is severe, hydrogen ion loss predominates, with paradoxical acid urine. Cataracts may occur in dystrophia myotonica, inborn errors of metabolism, chromosomal abnormalities, diabetes mellitus, corticosteroids therapy or following trauma. It may develop as a central, anterior, posterior fibroid or grow laterally in the broad ligament. The distal lumen pressure should always be displayed, to alert to accidental wedging. Prostaglandin Self-administered vaginal suppository containing prostaglandin following an unprotected intercourse, by virtue of its luteolytic effect on the ovary and its increased motility effect on fallopian tubes and the uterus, prevents implantation and brings about menstruation. A vesicovaginal fistula may result from ischaemic necrosis or a difficult forceps delivery in cases of disproportion, while a rectovaginal fistula is the result of a complete tear of the perineum or a suture which perforates the rectal wall. Hormones with anti-oestrogenic activity also suppress endometriosis and are used therapeutically. Radioimmunoassay is currently used to estimate the plasma progesterone levels in mid-luteal phase in cases of infertility. It may be congenital in origin or the result of infection, injury, neoplasm or a diverticulum. Urinary tract-urethral caruncle, papilloma and carcinoma of the bladder may be mistaken for genital tract bleeding. The term is sometimes reserved for drugs acting directly at vascular smooth muscle. In the female, the phallus (clitoris) is rudimentary, the urethra opens into the vestibule, the labia majora are smooth and bifid and do not possess a dartos muscle, and a vagina is present. The gland is crenated, the lumen contains mucous secretion and the inner border of the cells is irregular. Considerable stabilisation may be required before transfer, avoiding transfer of unstable patients. Other investigations may be required to rule out other causes of associated bladder neck instability.

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Gas chromatography: Direct demonstration of compounds characteristic of mycobacteria shows great promise (90% sensitive) to provide rapid diagnosis. Colposcopic Findings Meisels described colposcopic appearance of condylomas as patches of raised projection of acetowhite epithelium with speckled appearance. The normal uterus is not a static organ; its position is altered by the state of the bladder which, when full, displaces the uterus backwards. There is no change in the secondary sexual characteristics since these are already established. Polymenorrhagia is frequently observed when women resume menstrual activity after a delivery. The vaginal cytology during the different phases of the menstrual cycle is as follows: 1. The high cost of vaccine precludes the prophylactic use in general population as of today. Interstitial fibroids cause dysmenorrhoea more than subserous fibroids which cause more of heaviness and dull pain. Hypoventilation and V/Q mismatch due to pain, lung contusion and sputum retention are now thought to be more important. In young women, deep conization of the cervix can lead to midtrimester abortion, premature labour and cervical dystocia. Formerly used rather indiscriminately to increase 594 Venousadmixture the vegetative state is considered to be persistent when it lasts >1 month and permanent after >6 months. Has been used to treat lactic acidosis, although randomised trials have not found an increase in survival. The position of the catheter tip is also important; a continuous column of blood between the catheter and the left ventricle only occurs if the tip lies in zone 3 of the lung (see Pulmonary circulation). The important complications of haematoma of the vulva are haemorrhage with subsequent anaemia and local infection. Metronidazole does not reduce the number of lactobacilli unlike clindamycin and may be considered superior to the latter. Treatment Small and asymptomatic uterine fibroids do not require removal or medical treatment. Devices should warn of adverse changes in the state of the patient, and of altered functioning of anaesthetic equipment. Ultrasound scan reveals a fetal shadow and ultrasonic fetal maturity corresponds to uterine size. Causes less nausea/vomiting than ergometrine and does not cause hypertension (but see below). Nucleoside analogue antiplatelet drug, used in combination with aspirin in patients with acute coronary syndromes. Apart from the beneficial effects of lactation on the newborn, it is emphasized as the natural method of family planning in the first 6 months puerperium. Splits to enclose sternohyoid, sternothyroid, omohyoid, sternomastoid and trapezius muscles. It causes no discomfort and no douching is required when these precautions are observed. Group of autosomally inherited disorders involving decreased production of the or chains of haemoglobin (Hb). If the androgens are not elevated until after the 20th week, by that time the external genitalia have fully formed; the only masculine effect is an enlarged clitoris. Also introduced bobbin flowmeters, portable anaesthetic apparatus and other equipment. Restricting fluid intake, psychotherapy and treating the cause are also of importance. Complete cure should be ensured to avoid late sequel such as diabetes, hypertension, cardiovascular disease and hyperlipidaemia.

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Myomectomy should be performed in the preovulatory menstrual cycle to reduce blood loss during surgery. On asking the patient to contract her pelvic floor muscles, the tone of these muscles can be estimated. Persistent pyometra definitely indicates the need for a hysterectomy and bilateral salpingo-oophorectomy in postmenopausal women. Involves the following steps: depolarisation of the postsynaptic membrane at the neuromuscular junction. This postradiation process is not immediate or spectacular but may develop over months or even years, and the patient may well be cured of the local disease to succumb at a later date to the urinary obstruction (Chapter 38, Cervical Intraepithelial Neoplasia, Carcinoma of Cervix). Women are more prone to faecal incontinence than men, and elderly women suffer more than younger women. There is an increased risk of repeat scar ectopic pregnancy as well as placenta accreta. Chronic Cystitis Chronic cystitis caused by descending infection from the kidney is a urological problem and such patients should be handed over to the urologist. Due to potentially severe side effects, its use is restricted to specific infections (severe chest infections, complicated skin and soft tissue infections and pelvic inflammatory disease) that have failed to respond to other agents. Delayed in Eskimo girls as compared to girls living in the tropics Psychological state. The modern inhalational anaesthetic agents, especially sevoflurane, may react with soda lime if the latter is warm and very dry. Culdoscopy is now reintroduced in selective cases when laparoscopy is contraindicated or difficult. Spinal anaesthesia has been claimed to be safer than epidural anaesthesia, since the needles are finer. Each levator ani muscle consists of three main divisions: the pubococcygeus, the iliococcygeus and the ischiococcygeus. More complicated psychological questionnaires for analysis of personality and pain. Lack of these hormones in a menopausal woman leaves only the basal cells with a thin vaginal mucosa. These utilise an analogue-to-digital converter to translate measured voltages (sampled at close, regular time intervals) into digital information that is then displayed on liquid crystal or light-emitting diode panels. Lesions of the uterine appendages: n Prolapsed ovaries associated with retroversion cause deep dyspareunia. Has been used to investigate cardiovascular disease, especially valvular disease, and to determine systolic time intervals. In unit time, the volume of O2 leaving the lungs equals the volume of O2 in blood draining ventilated alveoli plus the volume of O2 in shunted blood. Vulval and vaginal warts during pregnancy mandate caesarean section to avoid papilloma laryngitis in the neonate. A new spermicidal cream, Tenofovir, prevents viral attachment to the vaginal mucosa and is nonirritant and is under development. This includes the pubocervical fascia anteriorly and the rectovaginal fascia and septum posteriorly. Advantages over spinal or epidural local anaesthetic agents are the lack of sympathetic, motor or sensory blockade, and the ability to provide analgesia distant to the level of injection. All have similar antibacterial activities (Gram-positive and some Gram-negative bacteria, mycoplasma, rickettsia and toxoplasma) but varying properties otherwise; thus the latter three drugs have longer durations of action than erythromycin and cause less nausea and vomiting. The perforation is more common if the uterus is soft as in pregnancy and in malignancy. Helium/O2 mixtures (which are less dense than air/O2 mixtures) may decrease work of breathing and improve oxygenation. Three grams daily of percutaneous gel of oestradiol with cyclical progestogen is easy to apply.

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Data from monitoring devices are incorporated with information provided by the anaesthetist/intensive care staff. The dotted line denotes the curve for a test where prediction is no better than chance Recovery position Record-keeping. The presence of the fundus seen laparoscopically indicates it is a septate uterus. About 50% women are asymptomatic carriers of infection, but majority complain of vaginal discharge without itching. The antigens which are being experimented upon are: n n the surgical technique should be simple and quick. It is also observed that even when a lesion is detected, it may not be the cause of the chronic pelvic pain, i. An asymptomatic fibroid may require observation whereas an ovarian solid mass needs prompt surgical removal. Airway management is complicated by haematemesis and steps to avoid aspiration of blood and gastric contents must be taken. The glands sometimes show a characteristic appearance in the later proliferative phase as if the glandular the Secretory Phase Progesterone induces secretory changes only if the endometrium is primed by oestrogen, which produces progesterone receptors in the endometrial cells. The ducts grow, descending caudally and medially by progressive development of a solid bud that canalizes simultaneously with its downward growth. Modern pacemakers are checked and adjusted via radiofrequency programming without requiring removal, and recorded data downloaded for analysis of cardiac function. As cellular immunity develops, destruction of the tubercle bacilli begins, leading to caseation necrosis. Their significance lies in the diagnosis of ovarian pain, ovulation monitoring and their potential for malignancy as in undescended testes. Temperature-sensitive cells are present in the anterior hypothalamus (thought to be the most important site), brainstem, spinal cord, skin, skeletal muscle and abdominal viscera. A clean dissection of the external iliac glands can only be made if both vessels are completely mobilized as some of the glands lie lateral to the vessels between them and the lateral pelvic wall. The uterus remains bulky following myomectomy and requires to be anteverted by plicating the round ligaments with nonabsorbable sutures. It takes 3 months to occlude the tube, during which period other contraceptive is required to protect against pregnancy. The sources of stem cells were until recently seen in bone marrow, embryo, amniotic fluid and umbilical cord blood but now in menstrual fluid as well. Digital devices benefit from greater portability and the option to apply processing algorithms to recorded signals. Surgical procedures like tubectomy (especially Madlener-7%), by virtue of spontaneous reanastomosis, and tuboplasty may end up in partial stenosis at the anastomosis site favouring ectopic pregnancy. In patients for whom the pessary test proves that the symptoms and infertility are caused by retroversion. Thought to bind to opioid receptors in the substantia gelatinosa of the spinal cord, modulating pain pathways. Complications include hypotension, genitofemoral neuritis, bleeding into psoas and epidural, subarachnoid or iv injection. The gland also secretes calcitonin, important in calcium homeostasis, from parafollicular (C) cells. The vasospasm is selective as it only affects the superficial layers and does not extend to the basal layer, which is thereby assured of an adequate blood supply necessary for regeneration. Clinically the patient suffers from manifestations such as abdominal pain, leucorrhoea, menorrhagia, congestive dysmenorrhoea, dyspareunia, backache and infertility. At the level of C6, major anatomical structures within the layer of skin, fat and subcutaneous tissue may be described in terms of fascial layers. Anaesthetic considerations: patients should be nursed sitting up preoperatively, to minimise facial and neck swelling. In pathological conditions, implantation may occur anywhere outside the normal uterine cavity, the subsequent gestation being called ectopic.

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Afferent and efferent nerve supply is mainly vagal via oesophageal plexuses, but also via sympathetic nerves. The treatment should be based on the age of the woman, her desire to retain fertility, previous treatment and severity of menorrhagia. Cytotoxic immunosuppressive drug used in organ transplantation, especially in combination with ciclosporin and corticosteroids. The extracted mass is assembled to ensure that the fetus has been totally extracted. The stumps of these ligaments are crossed and stitched together in front of the cervix. Ovarian Tumours Associated with Pregnancy the ovarian tumour discovered during pregnancy is an enlarged corpus luteal cyst, a benign as well as a malignant tumour. This formed the basis upon which much of the modern work on the sex hormones rests. Lactation is also contraindicated in a woman treated for breast cancer, because of the risk of developing cancer in the opposite breast. Metaplasia is benign but atypical metaplasia developing under the adverse environment such as pH, hormonal influence (oestrogen), virus and mutagens become precursors of cancer cervix. The girl will require oestrogen therapy for the development of the breasts as well as to prevent osteoporosis. Other Imaging Modalities Radiological investigation such as hysterosalpingography is utilized for studying the patency of the fallopian tubes in an infertile patient. Submucus polyp on the other hand is larger than 1 cm, sessile or often pedunculated, mobile. The best specimen is one obtained by masturbation in the vicinity of the laboratory, since this guarantees its freshness. All parts may be damaged during anaesthesia; the deeper the damage, the more extensive is the treatment required. Treatment Treatment of vaginal foreign bodies is to remove them, if necessary, under anaesthesia. Rupture of a Chocolate Cyst Rupture of a chocolate cyst causes shock and collapse, with acute abdominal pain. Opens reflexly during swallowing, and helps to prevent retrograde passage of gastric contents into the oesophagus via: increased muscle tone: muscle of the sphincter zone, especially the inner circular layer, has higher resting tone than other oesophageal muscle, possibly via increased calcium ion uptake and utilisation. Total spinal blockade results in apnoea and loss of consciousness, with fixed dilated pupils. Amoebiasis Amoebiasis of vagina appears as a fungating subcutaneous ulcer causing foul smelling discharge and postmenopausal bleeding. Acute haemorrhage or perforation may present with vomiting, shock and hypovolaemia. It may involve any part of the vulva, perianal area, perineum or skin of the adjacent thighs. Devices that convert one form of energy to another, usually to electricity in monitoring systems. Normal use of circle systems is not thought to result in such low levels of moisture, but they have been found after prolonged passage of dry gas through the absorber. Menstrual fluid is recently discovered to contain the stem cells and may prove useful in stem cell therapy. Cyclical hormones stimulate its growth, but continuous hormone secretion or therapy suppresses it. Endometrial hyperplasia may be simple or glandular whose malignancy potential is low. Hence, it is important to use selective culture media in all cases where response to treatment is disappointing. Virilizing Mesenchymoma Virilizing mesenchymoma and other virilizing tumours of the ovary are grouped together here for convenience. Arrhythmias and cardiac arrest may occur; resistant ventricular arrhythmias are particularly likely with bupivacaine. An r of +1 or -1 indicates complete positive or negative association respectively, whilst an r of 0 indicates no association.

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In the fertilized egg, the Y chromosome directs the development of the undifferentiated gonads into testes and absence of Y into ovaries 2 weeks later. The anatomy of the veins may vary considerably, especially that of the cephalic vein. Whereas a-fraction is identical in all (contains 92 amino acids), b-fraction is specific in its action. The cornified or fully mature cell represents the final phase of complete oestrogenic maturity. It is exemplified by the nocturnal enuresis in young girls when the urine is voided during sleep and when local reflex caused by threadworms may be found. Side effects: sedation, dizziness, headache, agitation, psychosis, visual disturbances. Further weakening of the pelvic floor muscle support and sphincteric control with advancing age is the cause of delay for the onset of symptoms. Apart from visualization of the tubal patency, peritubal adhesions and unsuspected endometriosis can be diagnosed. Incarceration of the prolapse is encountered in rare cases when, due to oedema and congestion, the prolapse becomes irreducible. In ascending infection, as seen in gonorrhoea, the mucous membrane is first affected. Endogenous b endorphin also stimulates insulin release and may contribute to insulin resistance. The blood supply to the pelvic ureter is principally from the lateral side, and the ureteric dissection should be done along its medial side. The condition is characterized by anosmia and maldevelopment of neurons in the arcuate nucleus. With aspirotomy forceps, the fetus is dismembered, crushed and extracted through the dilated cervix. Raw data are collected daily; the value recorded is a representative value for the day. Antituberculous drug used for prophylaxis against Mycobacterium avium in immunocompromised patients. In a tubal pregnancy, the most frequent implantation site is the ampulla (80%) because the plicae are most numerous in this situation and previous salpingitis is more likely to produce crypts here than elsewhere along the fallopian tube. The needle and syringe are used to locate the trachea through a small vertical incision in the cricothyroid membrane and the guide-wire inserted into the trachea. Trigger points can be located by pressing a finger where the woman complains of pain. In young women, topical progesterone is preferred to avoid side effects of oestrogen and testosterone. Regarding the barrier methods, female condoms and Today sponge may not be reliable with a patulous vagina and laxity of the perineum. Large unilateral effusions may displace the mediastinum (and thus the trachea) towards the opposite side. Investigations including methylene blue dye test, descending pyelography, cystoscopy and ureteric catheterization may be required to settle the diagnosis. Involves many abnormalities of the immune system, with autoantibodies a central feature; they may affect tissues directly or via immune complex deposition. Use of radioisotopes to label certain parts of the body in order to investigate organ function, either directly or attached to circulating cells. Only after three negative or below average counts, he should be proclaimed azoospermic or oligospermic. Exposure to ionising radiation is kept to a minimum with appropriate storage and handling of radioisotopes, minimal use of X-rays and appropriate use of shielding. Medicated devices which contain copper, progesterone hormone and other pharmacologic agents have been introduced. By the time ovarian malignancy is established, about two-thirds of these are already far advanced and the prognosis in such cases is unfavourable.

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Inadvertent instrumental perforation of the colon during laparoscopy: Non-surgical repair. Nestorone ring releases 150 mcg progestogen plus 15 mcg oestradiol daily-one ring remains effective for 1 year. Irritant if inhaled, they cause mild upper airway symptoms initially but pulmonary oedema several hours after initial recovery. In moderate and severe stenosis the area is reduced to < 2 and < 1 cm2 respectively. Progestogen-carrying device causes alteration in the cervical mucus which prevents penetration of sperm, in addition to its local action. Urine pregnancy test, Transvaginal sonography with colour Doppler blood flow studies and diagnostic laparoscopy should help in the management of the case. It comprises the anterior pituitary gland (adenohypophysis) and the posterior pituitary gland (neurohypophysis). In the acute phase, the patient must stay in bed and some relief may be obtained by the application of a hot water bottle over the bladder region. Usually affects the maxillary or sphenoid sinuses, although ethmoid and frontal sinusitis may also occur (and may result in cerebral venous thrombosis). Mortality is up to 30% if bleeding occurs, partly related to the underlying severity of liver disease. With increasing awareness that concurrent dehydration may be harmful, cases of hyponatraemia caused by excessive water intake have been reported. No adverse effect is noted on uterine fibroids, and it is oestrogen singly that increases their size. Viral shedding, however, tends to continue for weeks after the appearance of lesions. It is easily available, cheap, easy to carry, free from side effects and requires no instruction. In addition, the unreliability of identifying the lumbar interspaces by palpation may result in insertion of the needle at a higher vertebral level than intended. Peritoneal cavity contains yellowish-brown fluid in the cul-de-sac, and this contains prostaglandin responsible for pain. Progestogens exert anabolic effect and this partly accounts for some of the weight gain which may follow their administration. The laparoscopic study is indicated in patients with blocked fallopian tubes prior to undertaking tubal microsurgery. A Kelly stitch may be necessary to relieve her of stress incontinence, if this is present. Therefore, biopsy of the suspicious areas becomes necessary to prove the presence of endometriosis. The squamocolumnar junction is studied colposcopically when the Pap smear shows abnormal cells, and the abnormal areas are biopsied for cancer detection. Since this is compatible with normal reproductive capacity within the limits of its own infrequent ovulation, it requires no treatment. A properly performed episiotomy will very largely eliminate the risk of a third- and fourth-degree tear. The isthmus comprises the next and inner part of the tube and represents about one-third of the total length, i. An osmotic diuretic; it draws water from the extracellular and intracellular spaces into the vascular compartment, expanding the latter transiently. Ectopic decidual reaction is always very wellmarked beneath the peritoneum of the back of the uterus in the pouch of Douglas. The injury is not diagnosed at the time of surgery unless perforation also occurs.

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No systemic symptoms occur other than myotonia (involuntary sustained muscle contraction following stimulation), exacerbated by cold and rest, and relieved by exercise. When a known cancer of the cervix is accompanied by a slightly enlarged and locally tender uterus with fever, the most likely diagnosis is an associated pyometra. A routine breast examination may discover a breast lump, hitherto not recognized by the woman. High levels of fluoride have never been reported, even after prolonged surgery, but avoidance in renal impairment has been suggested. During pregnancy, the normal discharge is increased in amount because of the vascularity of the female genital tract. Primary myoma is also known as true broad ligament myoma and secondary myoma as false broad ligament tumour. The surgical removal or radiation should include all the regional glands for curative effect. Abnormal constituents include glucose, ketones, bilirubin, erythrocytes, large numbers of leucocytes and casts. Therapy should be organism-specific when possible, but broad-spectrum antibiotics are frequently necessary until the organism is identified. Higher concentrations are required clinically, in order to achieve Cm at the axons. Anatomy: the maxillary division (V2) of the trigeminal nerve passes from the Gasserian ganglion through the foramen rotundum into the pterygopalatine fossa, dividing into sensory branches and continuing as the infraorbital nerve. In an embryo, two ridges appear between fifth and eighth week, mesonephric (Wolffian) and paramesonephric ducts. Anaesthetic considerations are related to systemic manifestations of the disease and the effects of certain anaesthetic drugs worsening myotonia. Observe whether the movements of the cervix during the examination cause pain; this is seen in an ectopic pregnancy, as also in women with acute salpingo-oophoritis. Prolactin levels fluctuate episodically; therefore, several measurements may be necessary to confirm hyperprolactinaemia. Studies suggest that autoregulation is preserved in patients with cerebrovascular disease, in contrast to other inhalational agents. Rectal injury occurs mainly during vaginal surgery such as posterior vaginal repair for prolapse, repair of perineal tear, exenteration operation and vaginoplasty. A cell intermediate in type to the two already mentioned can be distinguished, and small rod-shaped cells are also present. Nerve supply is from branches of the ophthalmic (V1) and maxillary (V2) divisions of the trigeminal nerve: skin: - supratrochlear branch of the frontal nerve (V1). The signs and symptoms of pyelonephritis are pain and tenderness in the loins, with high temperature and frequent rigours, headache, vomiting and furring of the tongue. Acute renal failure (see Acute kidney injury for definitions, diagnosis and management). Used to illustrate the effect of gravity on regional pulmonary circulation, P1, P2 and P3 representing arterial, alveolar and venous pressures respectively. Once again oestrogen effects on the genitalia are apparent, the labia majora appear thick and full and tend to cover the labia minora, the clitoris appears prominent-the clitoral index (glans width 3 length) should not exceed 6. Also a prokinetic drug, increasing gastric emptying and lower oesophageal sphincter pressure via a peripheral cholinergic action, but will not reverse the effects of opioid analgesic drugs in this respect unless given iv.