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In these cases, the small chemical is called a hapten, and the large molecule to which it is conjugated is called a carrier. From these informations, the national plan outlay is formulated and the impact of the health care delivery system in a given period of time is evaluated. Maternal infections during pregnancy by virus (rubella, chickenpox, measles, mumps, poliomyelitis), bacteria (Treponema pallidum, Tubercle bacillus) or protozoa (Toxoplasma gondii, malaria parasites) may be transmitted to the fetus across the so-called placental barrier and affect the fetus in utero. The deep perineal pouch is formed by the inferior and superior layer of the urogenital diaphragm-together called urogenital diaphragm or triangular ligament. They show a series of grooves or sulci that are separated by intervening areas that are called gyri. Preconceptual phase is the time to identify any risk factor that could potentially affect the perinatal outcome adversely. The required deficit of 24 hours as calculated from test feeding is to be divided by the number of feeds to be given in 24 hours. Thus, only mediolateral or median episiotomy is done commonly and as such their relative merits and demerits are given in the tabulated form (Table 37. The infection causes exudation and formation of an indurated mass usually confined to one side of the uterus. The millions of resulting variations in structure are concentrated in the antigen-binding hypervariable regions of both heavy and light chains and thereby determine specificity for antigens. The chorionic villi on the decidua capsularis gradually Chapter 2 Fundamentals of Reproduction 29 undergoes atrophy from pressure and become converted into chorion laeve by the 3rd month and lies intervening between the amnion and decidua on its outer surface. Sudden hypotension following postpartum hemorrhage may cause infarction of the gland (Sheehan Syndrome). Factors responsible for cardiac failure: (1) Advanced age (2) Cardiac arrhythmias or left ventricular hypertrophy (3) History of previous heart failure (4) Appearance of "risk factors" in pregnancy are: infection, anemia, hypertension, excessive weight gain and multiple pregnancy (5) Inadequate supervision. The sense of smell is believed to be perceived in both the primary and secondary olfactory cortex. Acidosis should be corrected by intravenous administration of sodium bicarbonate 4. The abortion has to be performed confidentially and to be reported to the Director of Health Services of the State in the prescribed form. To improve the standard and quality of care by organizing refresher courses for the health care personnels. Venous drainage is through pampiniform plexus, to form the ovarian veins which drain into inferior vena cava on the right side and left renal vein on the left side. The uterus feels soft and elastic in contrast to firm feel of the nongravid uterus. In areas where eclampsia is frequently encountered, it is obvious that the obstetric care is inadequate. Unfortunately, one may have to perform such operations while working in the unorganized sector. A lateral projection of the breast towards the axilla is known as axillary tail of Spence. The ventral grey columns are present, but are separated from the central grey matter by decussating pyramidal fibres. At least, half of the total protein should be first class containing all the amino acids and majority of the fat should be animal type which contains vitamins A and D. The intermediate two-thirds of the crus cerebri are occupied by corticospinal and corticonuclear fibres. The posterolateral sulcus lies in line with the dorsal nerve roots of spinal nerves, and gives attachment to rootlets of the glossopharyngeal, vagus and accessory nerves. Behind the nipple, the main duct (lactiferous) dilates to form ampulla where the milk is stored. It increases HbF, improves red cell hydration and reduces polymerization of HbS and the crises. Hematocrit level is checked at intervals during the procedure to determine the volume. The pars posterior of the hypophysis is associated with the release into the blood of two hormones.

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An adenoma arising from chromophobe cells can become quite large and can produce pressure effects as follows. Apart from pregnancy, it may form in cases of generalized edema, marked obesity or in Cushing syndrome. The main advantage of parenteral therapy is the certainty of its administration to correct the hemoglobin deficit and to fix up the iron store. Colloids (albumin or Haemaccel) remain in the vascular tree and they withdraw fluids from the interstitial space. The three constrictors are so arranged that the inferior overlaps the middle, which in turn, overlaps the superior. Flexion is essential for descent, since it reduces the shape and size of the plane of the advancing diameter of the head. Rapid expulsion is due to the combined effect of hyperactive uterine contractions associated with diminished soft tissue resistance. The intense cough that is set up on the entry of even a small particle is a protective mechanism against suffocation. Blood transfusion is required if the blood loss is more than average during the operation (average blood loss in cesarean section is approximately 0. In cases where advanced refusal of blood products is known and the potential for bleeding anticipated. Almost two-thirds of this is a type of antibody called IgA, most of which is produced by activated B cells and plasma cells in the gastrointestinal tract. Removal is done by making a 2 mm incision at the tip of the implant and pushing the rod until it pops out. The lower segment elongates and becomes progressively thinner to accommodate the fetus driven from the upper segment. Complement fragments generated by the alternative pathway provide second signals for B cell activation and antibody production. The primary concern is not only to correct anemia but also to make the patient fit to withstand the strain of labor and blood loss following delivery. Side effects are: Maternal and fetal hyponatremia, acute pancreatitis, rise in uric acid levels, and neonatal thrombocytopenia. The lateral one-sixth is occupied by similar fibres from the temporal, occipital and parietal lobes. Chronic placental insufficiency leads to intrauterine hypoxia with passage of meconium. If there is risk of vomiting and aspiration, intravenous administration of 10% glucose in amount of 60 mL/kg body weight per day may be given to a term baby on 1st day through a catheter inserted into peripheral or umbilical vein. Between the ventral and dorsal grey columns an intermediate zone is sometimes described. To mark it draw a small oval just in front of, and above, the angle of the mandible. Other lectins are soluble proteins in the blood and extracellular fluids (discussed later). Collectins and Ficolins the collectins are a family of trimeric or hexameric proteins, each subunit of which contains a collagen-like tail connected by a neck region to a calcium-dependent (C-type) lectin head. Expression of breast milk or artificial removal of breast milk is not generally needed where breastfeeding is normal. The probable causes of incarceration are: (a) Projected sacral promontory; (b) Uterine adhesions; (c) Pelvic tumor; (d) Idiopathic (majority). The echo strength (strength of the reflected sound) depends mainly on the following four factors: (a) acoustic impedance mismatch. The decompression of the abdomen is done by simple puncture with a wide bore needle which is soon followed by spontaneous delivery. When resistance is encountered, by ordinary law of mechanics, the short arm descends and the long arm ascends resulting in flexion of the head. From here draw a horizontal line that runs forwards to end just behind the neck of the mandible. Intelligent observation, prompt recognition of the abnormality and adequate measures to rectify the defect can be life saving in many occasions. It may be present from the beginning of labor or may develop subsequently after a variable period of effective contractions.

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Quantitative changes in the constituents can be done by dilution followed by addition. Delayed complications: (1) Necrotizing enterocolitis; (2) extrahepatic portal hypertension due to thrombosis of portal vein and (3) other complications are mostly attributed to prematurity, hyperbilirubinemia and hypoxia. The superior olivary complex (made up of several nuclei) which lies dorsomedial to the lateral lemniscus. The preganglionic fibers of the sympathetic nerves arising from the spinal cord pass through the ganglia of the sympathetic trunk to aorticorenal plexus where they synapse. Failure of cervical dilatation may be due to-(a) Inefficient uterine contractions (see p. The loose peritoneum of the uterovesical pouch is cut transversely and pushed up and down. Control of activities necessary for survival of the species including sex behaviour. A, Neutrophils and monocytes that arise in the bone marrow, circulate in the blood, and are recruited into tissue sites of infection or injury, where they eliminate infectious pathogens, clear dead tissues, and repair the damage. The more dilutions that are required, the higher the titer of the antibody molecules specific for a particular antigen. The commonest cardiac lesion is of rheumatic origin followed by the congenital ones. Intrapartum umbilical artery Doppler study was poor to predict umbilical artery acidosis. It tends to occur initially on the cornu before spreading to other areas, more specially over the placental site. Face and Mouth: Face is looked for hypertelorism (eyes widely separated) or low-set ears (trisomy 9, 18, triploidy) or facial nerve injury. Step V: Routine exploration of the uterovaginal canal to exclude rupture of the uterus or any other injury. The impregnation is presumed to occur by a spermatozoa which passes through the normal half of the uterus and tube. Nipple soreness is avoided by frequent short feedings rather than the prolonged feeding, keeping the nipples clear and dry. Bottle-It is used when the baby can suck and swallow but cannot manage to express the milk out from the breast. At places, placental or decidual septa project from the basal plate into the intervillous space but fail to reach the chorionic plate. The maternal portion of the placenta amounts to less than one-fifth of the total placenta. Formation of trilaminar embryonic disk: Fourteen days after fertilization, proliferation of ectodermal cells in the midline, leads to formation of primitive streak. Mast cells are also activated when they recognize microbial products, independent of IgE, and in this way they function as tissue sentinels of the innate immune system. On no account, traction should exceed 30 minutes As soon as the head is delivered, the vacuum is reduced by opening the screw-release valve and the cup is then detached. The causes are: (1) Previous damage to the uterine walls following dilatation and curettage operation or manual removal of placenta. Once formed the position does not alter Upper segment contracts and retracts with relaxation in between; lower segment remains thick and loose. Finally, tubal rupture occurs when the muscles and the serosa are maximally stretched and undergo necrosis. Although paracervical block may be used from 5 cm dilatation of the cervix, it is most useful toward the end of the first stage of labor to remove the desire to bear down earlier.

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Calcium is stored within the cells in the sarcoplasmic reticulum and in mitochondria. The T cells also stop expressing L-selectin and start expressing ligands for E- and P-selectins. All these plasma proteins are called acutephase reactants because they are elevated in the blood during acute inflammatory reactions, and their increased production is part of the acute phase response to infection and other insults. The improvement and long term prognosis may be attributed to the following factors: (i) Recognition of high-risk factors related to choriocarcinoma. The important reasons are: (i) lack of public awareness, (ii) many pregnancies are unplanned. In the case of proteins, the formation of some epitopes depends only on the primary structure, and the formation of other determinants reflects tertiary structure, or conformation (shape). The tuberal (or infundibulo-tuberal) region includes the infundibulum, the tuber cinereum and the region above it. If moderate traction leads to progressive descent of the fetal head, the delivery is completed vaginally, if not cesarean section is done immediately. Intrauterine growth restriction and low-birth-weight babies-Apart from preterm delivery, intrauterine nutritional deficiency may be responsible for such low weight babies which are more vulnerable to biochemical, neurological and respiratory complications resulting in high perinatal deaths of about 50% when the birth weight is less than 2 kg. The dose (amount) and duration of teratogen exposure may cause variable response from no effect level to lethal level. Pathological anatomy of the uterus: There is gradual increase in intensity, duration and frequency of uterine contraction. Microbes and high-molecular-weight antigens are taken up by sinus macrophages and presented to cortical B lymphocytes just beneath the sinus. The woman presents with dizziness or light headedness on standing upright abruptly or following standing for a prolonged period. To complete the marking of the lobe, join the lower end of the posterior border to the lateral end of the lower border of the isthmus by a broad line convex downwards. It extends from the isthmus and ends at the external os which opens into the vagina after perforating its anterior wall. After maturing, B and T cells leave the bone marrow or thymus, enter the circulation, and populate peripheral lymphoid organs. It is performed as an outpatient procedure using a plastic disposable cannula (up to 12 mm size) and a 60 mL plastic (double valve) syringe. The cavity is loosely packed with gauze which should be replaced after 24 hours by a smaller pack. Complications of polyhydramnios are grouped into (a) Maternal and (b) Fetal (see p. The cases are judiciously selected and symphysiotomy may be done as an alternative to risky cesarean section when there is a likelihood of scar rupture in subsequent labors. Sildenafil is used as a potent vasodilator as it increases endogenous nitric oxide. Severe-(1) the onset is acute with high rise of temperature, often with chills and rigor, (2) Pulse rate is rapid, out of proportion to temperature, (3) Often there is breathlessness, coughs, abdominal pain and dysuria, (4) Lochia may be scanty and odorless, (5) Uterus may be subinvoluted, tender and softer. This simple procedure prevents the serious consequence of mucus blocking the air passage during vigorous inspiratory efforts. Remote prognosis during future pregnancy is very much unfavorable because of high risk of scar rupture. Restitution: There is movement of restitution to the extent of 1/8th of a circle in the opposite direction of internal rotation of the head. The operator must have knowledge, experience and skill to use and also the willingness to abandon the procedure when felt difficult. The collection is done through strainer consisting of 4-5 layers of sterile gauze pieces into a bottle containing citrate solution (3. Laparoscopy is the gold standard test; however, it is invasive and only used where diagnosis is uncertain. About 50% of first trimester spontaneous abortions and about 5% of stillborn infants have chromosomal abnormalities.

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As the uterus grows, the fundus rises spontaneously from the pelvis beyond 12 weeks. Gastrointestinal Gastrointestinal side effects are due to loss of epithelial cells. However, during labor, accurate information may be obtained by palpation of the sagittal suture and fontanelles through the open cervix. The optimum interval between uterine incision and delivery should be less than 90 seconds. Traction over this flexion or pivot point either by ventouse or forceps promotes flexion and presents smaller diameter to the pelvis. Radiotherapy for symptom palliation Radiotherapy is used to control some symptoms caused by metastatic disease. Technique: the pudendal nerve may be blocked by either the transvaginal or the transperineal route. Understanding the sequence of sexual events and the interplay of physical factors (pain, lubrication, environment) helps to deal with the root cause. Imperfect retraction and a large placental site are responsible for excessive bleeding. Deficient progesterone secretion from corpus luteum or poor endometrial response to progesterone is the cause. Factors facilitating descent are-(1) uterine contraction and retraction, (2) bearing down efforts and (3) straightening of the ovoid fetal especially after rupture of the membranes. Prophylactic intravenous ergometrine or syntometrine following the delivery of the anterior shoulder should not be given as it may produce further rise of blood pressure. Induction is done by the following methods: Prostaglandins are more effective than oxytocin in such cases. Overflow incontinence following retention of urine should first be excluded before proceeding to differentiate between the other two. Many other cell types, including epithelial cells and other tissue cells, also possess intrinsic mechanisms for defending themselves against microbes. It is characterized by the overgrowth of endometrial cells and is caused by excess unopposed oestrogens, either endogenous or exogenous, similar to endometrial cancer, with which it shares a common aetiology (see b Endometrial cancer: aetiology and histology, p. Most neurons give off a number of short branching processes called dendrites and one longer process called an axon. Total pulmonary Chapter 5 Physiological Changes during Pregnancy 63 resistance is reduced due to progesterone effect. The cervix and the vault of the vagina are inspected with the help of good light source placed behind. The operation should be done by an experienced surgeon with the help of an expert anesthetist. The hands are to be placed flat on either side of the umbilicus to palpate one after the other, the sides and front of the uterus to find out the position of the back, limbs and the anterior shoulder. It increases the cardiac output and renal blood ow hYdRalaZine 582 Textbook of Obstetrics table 34. Recurrent breech: On occasion, the breech presentation recurs in successive pregnancies. The spatial arrangement of different epitopes on a single protein molecule may influence the binding of antibodies in several ways. There is marked hypertrophy of the volume (mL) muscle and the sheath of the ureter especially Inspiratory 2500 2650 +10% the pelvic part probably due to estrogen. Pseudocyesis (Syn: Phantom, spurious, false pregnancy): It is a psychological disorder where the woman has the false but firm belief that she is pregnant although no pregnancy exists. There is hepatic gluconeogenesis and insulin secretion by the drugs (quinine) Metabolic acidosis (pH < 7.

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Chapter 52 Diencephalon, Basal Ganglia, Olfactory Region and Limbic System 1099 52. Management: Unlike inlet disproportion, clinical diagnosis of midpelvic and outlet disproportion can only be made after the head sufficiently comes down into the pelvis. However, in less than 5%, the babies may weigh more than 2500 g even when born before 37 completed weeks. If no significant improvement is evident clinically and hematologically within 3 weeks, diagnostic re-evaluation is needed. Absent cardiac activity in embryos is the most important factor in predicting poor pregnancy outcome. In terms of figures, the daily requirement during pregnancy and lactation is given in Table 10. Similarly, almost any drug used in pregnancy can cross the placental barrier and may have deleterious effect on the fetus. Advantages gained thereby are: (1) to minimize the risk of puerperal venous thrombosis by promoting arterial circulation and preventing venous stasis, (2) to prevent backache and (3) to prevent genital prolapse and stress incontinence of urine. Now carry the line downwards and backwards to reach a point just posteroinferior to the angle of the mandible. However, the diagnosis is revealed on laparotomy following termination as rupture. Many will have a previous history of intraepithelial neoplasia or invasive carcinoma of the vulva, vagina, or cervix. Continuous positive pressure ventilation to maintain arterial oxygen saturation of 95% is done. The separation is achieved by marked reduction in the uterine surface area of the placental site following delivery due to retraction. The effects of the tumour (adenoma) may be caused by pressure on surrounding structures, or by increased or decreased production of hormones. The method is based on identification of the fertile period of a cycle and to abstain from sexual intercourse during that period. The objective of curettage is to remove the necrosed decidua and the attached vesicles so as to accelerate involution and to reduce the irregular bleeding. The vulva and adjoining part are cleaned with cotton swabs soaked in antiseptic solution. Hydroxy urea should be stopped at least 3 months before conception as it is teratogenic. Sexually transmitted diseases should be treated before embarking on another pregnancy. After the birth of the baby, the uterus measures about 20 cm (8") vertically and 10 cm (4") anteroposteriorly, the shape becomes discoid. The procedure should be conducted in an operation theater keeping everything ready for cesarean section. Provided the patient is sure about her date of last normal menstrual period, a measurement of symphysis-fundal height in later month of pregnancy is a useful screening test for further investigation. Muscle tone and motility of the entire gastrointestinal tract are diminished due to high progesterone level. These antibodies opsonize the microbes and thereby promote their phagocytosis by neutrophils and macrophages, or kill the microbes by complement-dependent mechanisms.

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Respiratory-The patient may suffer from dyspnea or even remain in the sitting position for easier breathing. The lower end of this artery corresponds to the termination of the common carotid artery. Vomiting is a prominent feature, the vomitus being copious and bile stained (atresia is usually below the ampulla of Vater). The local differentiation within the mucosal lymphoid Migration of B Lymphocytes 55 tissues of B cells into IgA-secreting cells, combined with the homing of these cells into the mucosa, optimizes IgA defense against microbial invasion through the mucosal barriers. The areas to be included under the heading limbic system are not completely agreed upon. In contrast, repeated exposure to a microbe enhances the rapidity, magnitude, and effectiveness of adaptive immune responses. Asymptomatic patients, with a normal chest X-ray, are unlikely to have brain or other visceral metastasis. Mode of delivery in twins depends on fetal presentation, estimated fetal weight and gestational age (p. When the doctor fails to exercise that duty properly, he is found to be negligent. It is not due to increase in aldosterone which, in fact, is diminished in preeclampsia. This is a collection of lymphoid tissue present in relation to the roof of the nasopharynx (45. The presence of multiple identical determinants in an antigen is referred to as polyvalency or multivalency. Abnormal color: Deviation of the normal color of the liquor has got clinical significance. One hormone containing three atoms of iodine in each molecule is called triiodothyronine or T3. Contraception failure (c) Use of progestin only pill or postcoital estrogen Previous ectopic pregnancy preparations increases the chance of tubal Tubal reconstructive surgery pregnancy probably by impaired tubal motility. Rupture of a rudimentary pregnant horn has got a special clinical entity and is grouped in ectopic pregnancy. On examination: (1) There is pallor of varying degrees; evidences of glossitis and stomatitis. It provides traction in the correct axis of the pelvic curve and as such, less force is necessary to deliver the head. Chapter 39 Special Topics in Obstetrics 721 Other postulations are- Maternal fetal cell trafficking and microchimerism: Maternal tolerance of fetus is due to bidirectional cell trafficking between the mother and fetus. Effects on labor: (1) There is increased incidence of abnormal uterine contraction and prolonged labor; (2) operative interference and cesarean delivery is increased and so also difficulty in cesarean section; (3) shoulder dystocia is likely and (4) anesthetic hazards (difficult intubation) are high. Fetus papyraceous or compressus is a state which occurs if one of the fetuses dies early. More extensive primary surgery can limit ability of specialist centre to perform radical debulking and should be avoided, if possible. From the trabeculae develops the stem villi on 13th day which connect the chorionic plate with the basal plate. However, thrombosis occurs to occlude the torn sinuses, a phenomenon, which is facilitated by hypercoagulable state of pregnancy. The affinity of the interaction between the combining site of a single antibody molecule and a single epitope is generally represented by the Kd calculated from binding data. Fibroid: (1) the tumor is slow growing, often takes years (2) Amenorrhea is absent (3) the feel is firm, more towards hard but may be cystic in cystic degeneration (4) Positive signs of pregnancy are absent (5) Ultrasonography or immunological test for pregnancy gives negative result. The main efferents are to the spinal cord through the rubrospinal tract, and also to motor cranial nerve nuclei.

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If left uncared for, the case presents features of prolonged and obstructed labor. It is revealed during cesarean section in the first stage, during forceps application in the second stage and during manual removal in the third. Fetal well-being is assessed by clinical examination and also with cardiotocograph and ultrasonography for liqor volume and fetal weight. Vaginal delivery: the baby is invariably dead in most of the neglected cases and destructive operation is the best choice to relieve the obstruction. As such, a positive case should be subjected to repeat scan after emptying the bladder. Thus, continuation of pregnancy for few weeks hoping the baby to become mature enough to survive can only be justified in exceptional circumstances. Acceptance of risk There is an acceptance that some risk cannot be reduced or eliminated. The upper border of the fundus is located by the ulnar border of the left hand and this point is marked. Functional closure occurs soon after birth but anatomical closure occurs in about 1 year time. However, genuine cases are on record of gestation continuing to term in the Fallopian tube. Maternal blood vessels pass through all the layers to reach the intervillous space. Increased incidence of retained placenta is due to: (1) Increased surface area and (2) Morbid adhesion. Fetal perineal examination for external genitalia may be incorrect in the second trimester in 1% of cases. The dorsal and ventral cochlear nuclei lie dorsal and ventral, respectively, to the inferior cerebellar peduncle. To take high vaginal or cervical swab for culture, drug sensitivity test and Gram stain. Signs: (1) Varying degree of shock is a constant feature, (2) Abdominal examination-(a) Cupping or dimpling of the fundal surface, (b) Bimanual examination not only helps to confirm the diagnosis but also the degree. The roof and posterior wall of the nasopharynx form a continuous curve that rests on the posterior part of the body of the sphenoid, the basilar part of the occipital bone, and the anterior arch of the atlas. While, from the end of 20th week onwards, the measurement is taken from the vertex to the heel (crown-heel length). Because of their anatomic location, morphologists call these T cell zones periarteriolar lymphoid sheaths. The fetal foot is then grasped at the ankle and breech extraction is accomplished. The somatic distribution of uterine pain is that area of the abdomen supplied by T10 to L8. Trifling abnormality may be exaggerated for which unnecessary medication or risky operative interference is prescribed. Complicated - the tumor should be removed irrespective of the period of gestation. Forward leaning position (kneeling, hands and knees position) may help forward rotation and reduce back pain. Hazards of X-ray pelvimetry includes radiation exposure to the mother and the fetus (see p. Detection of fetal red cells in the maternal blood (in case of Rh isoimmunization) Modified Kleihauer-Betke acid elution test. The scalp is sucked into the cup and an artificial caput succedaneum (chignon) is produced. Formation of face All major structures form, complete ventricular septum (D-46), recognizably human External genitalia develop Skin is covered with lanugo. On the inferior aspect, the two hemispheres are separated by a deep depression called the vallecula. We will return to a detailed discussion of mast cells in the context of allergic diseases in Chapter 20. B-Lynch suture, isthmic cervical apposition suture, uterine and internal iliac arteries ligation or intervention radiology and uterine artery embolization (see p.