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The feasibility, success and patient satisfaction associated with outpatient hysteroscopic sterilisation. Most studies of interventions have either had no classification or have selected subgroups of women, for example those with a multiple pregnancy or those with a short cervix. These findings should be confirmed with a second opinion or repeat scan performed 7 days after the initial scan. Maternal suicide is a leading cause of death in postpartum women in some countries and is often by violent means. Most affected infants are asymptomatic or present with signs of minor haemorrhage such as petechiae. Management Women with suspected genital herpes should be referred to a genitourinary medicine physician, who will confirm or refute the diagnosis, advise on management of genital herpes and arrange a screen for other sexually transmitted infections. Measuring pregnancy intention and its relationship with contraceptive use among women undergoing therapeutic abortion. In vitro fertilization In vitro fertilization is where the mature oocyte is surgi cally removed from the ovary and then fertilized with sperm in the laboratory. Three conditions are included: hypothalamic amenorrhoea, hypogonadotrophic hypogonadism and hypopituitarism. Normal findings on examination of the cardiovascular system in pregnancy murmur at the left sternal edge is heard in nearly all women and may be remarkably loud and be audible all over the precordium. Failure of secondstage descent combined with excessive caput or moulding sug gests disproportion and requires critical assessment to decide the appropriate mode of delivery. Whichever closure method is used, it is vital to ensure optimum alignment of all layers: decidua to decidua, myometrium to myo metrium, and serosa to serosa. At first sight, it might seem that whether studies have used thresholds like 42 and 43 weeks of gestation or Table 23. Both systems classify features of the heart rate to assist with interpretation Fetal Monitoring in Labour 379 of fetal wellbeing and give guidance on management (Tables 27. Daily suppressive aciclovir 400 mg three times daily from 36 weeks of gestation should be given. They should not be offered ovulation induction until these issues are addressed as it is unlikely to work. An upper gastrointestinal contrast study is required in any infant who presents with bilestained vomiting in order to exclude malrotation and/or volvulus. This study, and a more contemporary one (during a Determination of the number of constituent layers of the dividing membranes (and therefore of membrane thickness). These include fluidfilled thermal balloon endometrial ablation and impedancecontrolled endometrial ablation. This study also found that the protection against gastrointestinal illness in breastfed babies persisted beyond the period of breastfeeding itself and, in the developed country setting at least, was not undermined by the early introduction of at least some supplements. There is a little more evidence in support of the use of amniotomy with oxytocin for augmentation of labour. However, if asphyxia is severe or happened some time before delivery, the infant will not develop spontaneous breathing; therefore, if despite advanced life support there is no sign of spontaneous breathing 20 min after birth, the outcome is extremely poor. In complicated cases, thickened meconium and obstruc tion lead to complications such as segmental volvulus, atresia, necrosis, perforation, meconium peritonitis (generalized) and giant meconium pseudocyst forma tion. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. This results in slower restoration of fetal haemoglobin than if blood is given directly into the circulation, and as a result is no longer the route of choice for fetal therapy. Counselling should be offered before, during and after investigation and treatment.

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Live births have been achieved by all these methods, although the technology for oocyte cryopreservation is less effi cient than for embryo cryopreservation and ovarian this sue freezing is still in its infancy [23]. The definitions can be seen to be a mixture of clinical and ultrasoundbased diagnoses and are often suggested prospectively and confirmed retrospectively. The possible mecha nisms for this are hyperandrogenism and insulin resistance [35]. They need not be admitted after either and the vast majority go home after misoprostol to pass the pregnancy at home. Decisions should be made in concert with parents and multidisciplinary teams (including neonatologists). Neonatal Care for Obstetricians 447 Communication following neonatal death In circumstances where neonatal death is the outcome, family support by neonatal staff should include the antenatal team wherever possible. The endometrium will proliferate from the basal layers of the decidua but this is influenced by the method of infant feeding. Ten adverse outcomes were reported from this group: four antepartum deaths, one neonatal death, one case of neonatal encephalopathy and four cases of fetal distress on admission in early labour. There is evidence that infants severely affected by rhesus disease have lower birthweights than matched controls. The contribution of this rise to the periovulatory phase of the cycle is unclear, but prevention of the preovulatory rise in serum progesterone concentration using progesterone receptor antagonists such as mifepristone prevents efficient ovulation. In caring for a woman during the early puerperium, the role of the obstetrician and midwife is to monitor the physiological changes of the puerperium, to diagnose and treat any postnatal complications, to establish infant feeding, to give the mother emotional support and to advise about contraception and other measures that will contribute to her continuing health. The threshold for investigation should be reduced in obese and morbidly obese women, for example women presenting with reduced fetal movements or with complications in labour. For most couples this will be after 1 year of unprotected vaginal sexual intercourse but couples should be referred earlier where the woman is 36 years or over or if there is a known clinical cause of infertility or predisposing factors for infertility. Most infants, chil dren and adolescents have chronic infection (lasting longer than 6 months) of the asymptomatic immunotol erant type. However, it is not certain if the radiological improvement seen will actually reduce the risk of fracture, as remineralization is not equivalent to the restrengthening of bone. The ovaries in most individuals consist solely of stroma and as there are no oocytes remaining, they are unable to produce oestrogen. In those women we advise cessation as soon as pregnant in order to avoid months prepregnancy with no renal protection. Detection of any cardiac abnormality should prompt a detailed evaluation for extracardiac anomalies. If any one of the following signs is present, a diagnosis of severe sepsis should be made with consideration of transfer to intensive care: 1) 2) 3) 4) 5) systolic blood pressure less than 90 mmHg; heart rate more than 130 bpm; oxygen saturation less than 91%; respiratory rate more than 25 per min; responds only to pain or unresponsive. Clinical manifestations include pneumonia, dissemi nated mucocutaneous lesions and visceral infection. Children are also affected both directly and indirectly, and there is also a strong correlation between domestic violence and child abuse, with suggested overlap rates of between 40 and 60%. Maternal serum markers are significantly affected by maternal character istics, including ethnicity, maternal weight, medical disease such as diabetes and the mode of conception. Detection of endometrial pathology using saline infusion sonography versus gel instillation sonography: a prospective cohort study. The presence of a partner or a relative may constrain discussion of domestic violence and could place the woman in greater danger. It is par ticularly useful in cases of multiple pregnancies, or a vanished twin pregnancy. Large pelvic masses including ovarian cysts and fibroids, palpable abdominally, clearly influence management and may militate against a laparoscopic approach if surgery is indicated. Fetal fibronectin Fetal fibronectin is a glycoprotein variant of the fibronectin family present in amniotic fluid, placenta and the extracellular substance of the decidua. Neurological conditions Neonatal encephalopathy Neonatal encephalopathy can be caused by hypoxic ischaemia due to birth asphyxia but also by other conditions including metabolic disorders and infections. Congenital pneumonia Congenital pneumonia is a relatively common problem associated with a variety of microorganisms.

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Contraindications to mifepristone/misoprostol are few but include chronic adrenal failure, inherited porphyria, coagulopathy, hypersensitivity to the medicines, and known or suspected ectopic pregnancy. Of these, about 13% will have problems at birth, such as hearing loss and learning diffi culties, with a similar number developing problems later. The risk of death for the abdominal approach is estimated as 1 in 4000 procedures. A metaanalysis comparing pregnancy outcome in two groups of lowrisk women, one with communityled antenatal care (midwife and general practitioner) and the other with hospitalled care, did not show any differences in terms of preterm birth, caesarean section, anaemia, antepartum haemorrhage, urinary tract infections and perinatal mortality. Antenatal strategy and decisionmaking these women ideally will have had prepregnancy counselling to ensure optimal timing, that disease is quiescent, medications and blood pressure control optimized and that they understand the risks of pregnancy. If an ago nist trigger is used, then the luteal phase support is often modified (see section on luteal phase support). Thrombosis and haemorrhage are major causes of morbidity in these conditions and pregnancy outcomes have historically been poor. Other possible causes of postmenopausal bleeding should be considered, such as cervical polyps, adnexal pathology and bladder pathology. Molecular genetic analysis of factor X deficiency: gene deletion and germline mosaicism. Lifestyle concerns At an early stage in the pregnancy women require lifestyle advice, including information on diet and food, work during pregnancy and social aspects, for example smoking, alcohol, exercise and sexual activity. This reduction in blood flow can lead to fetal distress, especially if the fetus is already compromised. Psychological sequelae to miscarriage are not uncommon and clinicians should be alert to the fact that depression, anxiety and post traumatic stress disorder may occur in these women. Most women requesting abortion will have decided to have a termination of pregnancy before coming to a healthcare provider for assistance [14]. However, women with fibroids not distorting the cavity behaved similarly to women with unexplained recurrent mis carriage, with 70% birth rates in both groups. However, causes may be lifethreatening and thrombocytopenia has implications for mode of delivery and the bleeding risk of mother and neonate. The place of delivery is debatable but there is an increasing trend for twins to be delivered in operating theatres so that there is immediate redress to emergency caesarean section if necessary. Women at high risk of preterm birth may be offered serial measurement of cervical length to assess their risk of preterm labour. Thyroid disease is common and the thyroid gland should be palpated and signs of hypothyroidism (dry thin hair, proximal myopathy, myotonia, slowrelaxing reflexes, mental slowness, bradycardia) or hyperthyroid ism (goitre with bruit, tremor, weight loss, tachycardia, hyperreflexia, exophthalmos, conjunctival oedema, oph thalmoplegia) elicited. Unlike 17hydroxyprogesterone caproate, natural progesterone has not been associated with any harm to either mother or fetus. There are conflicting opinions about the most appro priate strategies and methodologies that should be used to define normal fetal growth. Overarching principles of care are the need for careful isolation of these women to prevent the spread among other vulnerable pregnant women. No other biophysical test other than accurate measurement of blood pressure in the first trimester has either any clinical application or is practical enough to employ in clinical practice. Key to the clinical manifestations is the size of the mutant load transmitted and the tissue distribution of the abnormal mitochondria. Humoral immune response to conserved epitopes of Chlamydia trachomatis and human 60kDa heatshock protein in women with pelvic inflammatory disease. It is characterized by an excessive ovarian response resulting in multiple follic ular growth and large numbers of eggs collected. Severe preeclampsia: preeclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment. Supernumerary marker chromosomes detected in 100,000 prenatal diagnoses: molecular cytogenetic studies and clinical significance. In traditional statistical testing, the Pvalue is the probability of observing data similar to that observed by chance alone.

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Help for the socially disadvantaged and single mothers must be organized and ideally a onetoone midwife allocated to support these women. Next generation sequencing for aneuploidy has allowed for accurate identification and transfer of euploid embryos. Stents have been successfully placed and sonograpically controlled ureterostomy has been performed during gestation Outcomes largely predicted by baseline function and hypertension. Any focal neurological signs should be investigated with cranial imaging to exclude other pathologies but no specific treatment is recommended. It should be mentioned that the visualization of pelvic oedema caused by inflammatory disease of genital ori gin may be deceptive, since it can induce thickening of adjacent organ walls and suggest an incorrect diagnosis (appendicitis in particular) [70]. This counsellor may be a midwife, a health visitor or a lay person but the creation of a relaxed and confident environment is vital for successful breastfeeding. More recent studies have begun to elaborate a complex series of paracrine processes that operate within the tissues of the ovary and uterus to impose local regulation. Progesterone and metabolites, such as allopregnanolone, are produced by the ovary and the adrenals, and also de novo in the brain. The uteroplacental circulation is a low pressure system and its perfusion ceases at the height of a uterine contraction in the first stage of labour (where intrauterine pressures reach about 90 mmHg) and throughout practically all of a contraction when the woman is pushing in the second stage of labour (intrauterine pressures up to 250 mmHg). An increased incidence of admission to neonatal care was found in the delivery group [37]. Children with a normal solitary functioning kidney, with evidence of compensatory hyper trophy, have a small risk of future renal insufficiency. Simulation training can help to teach the technical skills required to perform intrapartum procedures safely, sup ported by direct supervision from senior clinicians and objective assessment of competence before moving on to independent practice. If there are any delays in establishing effective anaesthesia, then it is prudent to continue fetal and maternal monitoring, continuously feeding back to the anaesthesia team regarding current maternal and fetal wellbeing. The size of the Pvalue relates to the likelihood of the result occurring by chance. Increased neonatal mortality among normalweight births beyond 41 weeks of gestation in California. The early deaths took place within 4 weeks of admission due to organ failure associated with one or more of the following: fatal haemorrhage, metabolic upset from tumour lysis and very adavanced disease. There is a small risk of longterm hypertension and malignant transformation in the dysplastic kidney. However, there is risk of significant morbidity, including mobility issues and bladder and bowel dysfunction, and counselling by a neurologist is essential. This greatly minimizes the risk of fetal trauma, and nautical folklore has it that a child born en caul will never drown at sea. However, all women may choose to have a test of tubal patency prior to treatment if they prefer this approach. It also provides an opportunity to take swabs for microbiological assessment if there is a history of sexually transmitted infection or signs and symptoms of current infection. Diagnosis is made by the presence of two of the following three criteria: (i) oligo ovulation and/or anovulation, (ii) hyperandrogenism (clinical and/or biochemical) or (iii) polycystic ovaries, with the exclusion of other aetiologies of menstrual irregularity and androgen excess. By keeping the laparo scope inside the cannula as it is being withdrawn, it is possible to check that this port site is not bleeding and has not caught a loop of bowel or omentum. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. A painful episiotomy may make it very difficult for women to spontaneously micturate and retention of urine may occur. All women with preexisting diabetes should have blood tests for renal function and urine albumin creatinine ratios in each trimester. Certain physical activity should Antenatal Care 49 be avoided such as contact sports which may cause unexpected abdominal trauma. The overall metaanalysed measure of effect is represented as the diamond on the bottom and the lateral points indicate the confidence intervals. As the vaginal mass enlarges there may be associated difficulty with micturition and defecation.

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Cardiovascular disease is the principal cause of morbid ity and mortality in women. The lower segment of the uterus also stretches and relaxes and behaves physiologically more like the cervix than like the contractile upper segment of the uterus. However, prenatal treatment, only available in select fetal therapy centres, is associated with significant risk of preterm premature rupture of membranes and preterm birth. Such clinics make outpatient management much more convenient for the woman, and facilitate good communication between the relevant medical teams. A combination of general and neuraxial anaesthesia allows the mother to be awake for delivery, after which general anaesthesia can be induced for caesarean hysterectomy or other complicated surgery. Germline e and somatic mosaicism for a mutation of the ryanodine receptor type 2 gene: implication for genetic counseling and patient caring. These two apparently contradictory findings can probably be explained by the lack of power of the studies to detect a significant difference between drugs with little or no efficacy but a high placebo response rate. This will allow smaller diam eters to present as the head rises up through the pelvis. The aim is to induce a monofollicular response to insure this occurs, and a multifollicular response is avoided, all patients undergoing ovulation induction should have ultrasound monitoring through their first cycle of treatment. The first is the 24hour urine protein estimation and this requires that an assessment of sample completeness is undertaken, with measurement of creatinine excretion being the most common. This should be given by facemask with a reservoir bag, and the oxygen should be turned up to maximum at the wall in the emergency situation. Ultrasound features of meconium peritonitis include intraabdominal calcifi cations, hyperechogenic bowel, ascites and bowel dilatation. As most pregnant women prior to delivery are taking a nighttime longacting basal insulin and quickacting basal insulin with their evening meal, women being admitted for a planned induction should be encouraged to take their normal insulin doses the night before. Endometriosis is thought to influence fertility in several ways, including distorted pelvic anatomy, adhesions, pelvic inflammation, altered immune system functioning and impaired implantation. Shunting also allows restoration of flow of fetal urine into the amniotic cavity and thus prevents pul monary hypoplasia. Fetal intracardiac potassium chloride injection to expedite second-trimester dilation and evacuation. A precise diagnosis often needs to await postnatal or postabortal radiology or molecular testing. The theoretical risks of hypertension and thrombotic complications have not been encountered, nor have adverse neonatal effects. In outflow tract obstruction, surgical management depends on the level of obstruction. The introduction of ultrasound has changed the approach to many disorders in gynaecology. Causes of preterm labour Preterm labour is not a single disease entity but is a syndrome that may have one or more causes [9,10]. In adults, arthritis and arthralgia may occa sionally be seen after rubella infection. The prolonged use, or multiple changes, of antibiotics in the antenatal period may increase the risk of infection with resistant organisms. Approximately 10% will still have anal symptoms of urgency or incontinence at 3 months after birth. Decelerations are repetitive in nature when they are associated with more than 50% of uterine contractions. However, prostaglandin synthesis is also an important component of ovulation, and the use of powerful inhibitors of prostaglandin synthesis, such as nonsteroidal antiinflammatory agents, can lead to anovular cycles and involuntary infertility. Mothers may need haemostatic support to cover invasive procedures, delivery and the postpartum period and should be encouraged to have an active third stage. The rash is usually transitory, erythema tous and mostly located behind the ears and on the face and neck. Preconception and early pregnancy maternal haemodynamic changes in healthy women in relation to pregnancy viability. A video cable transmits the digital image data between the camera head, camera control unit, and monitor. If a caesarean delivery is being performed as an emergency, the anaesthetic team may need to decide quickly the safest method of anaesthesia for the mother and fetus.

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For example, if intrauterine growth restriction is classified as babies less than the 10th centile, then 10% of the normal baby population will fall into that category as well as those who may be truly growth restricted. Megaloblastic anaemia Worldwide, megaloblastic anaemia during pregnancy secondary to folate deficiency is common due to poor diet and increased folate requirements. Recognized risk factors include multiple pregnancy, hypertension (preexisting or related to pregnancy or preeclampsia), multiparity, increased age and AfroCaribbean race. Fluid instillation should be considered if the endometrium is not well visualized on unenhanced ultrasonography, or if within a thickened endometrium no pedicle artery is detectable on colour Doppler exami nation [27]. This is particularly important in women who are obese or smokers and are therefore at increased risk of venous thromboembolic disease. Since differentiation is often poor, most patients have mild masculinization or none at all, and the uterus, tubes and vagina are generally present. Menstruation Menstruation refers to the shedding of the superficial layers of the endometrium with subsequent repair in preparation for regrowth from the basalis layer. They have feelings of fear and confusion, particularly around their sexual orientation, and may express feelings of rejection and isolation. Repeated rotations and septations then occur which ultimately results in a fourchamber organ. In this chapter, we focus on practical guidance in per forming gynaecological ultrasound and discuss the role of different imaging modalities in common clinical con ditions encountered in gynaecological practice. Stillbirth 419 Ultimately, this results in a significantly increased risk of relationship breakdown between the parents following stillbirth [46, 47]. There may also be big ethnic variations in the expression of hirsutism, with women from South Asia and Mediterranean countries often having more pronounced problems, whereas those from the Far East may not have much in the way of bodily hair. A network consists of at least one neonatal intensive care (level 3) unit providing intensive care facilities, with specialist staff and facilities. Thalassaemia the thalassaemias are a group of inherited disorders characterized by reduced or absent production of the or haemoglobin chains. Baker [4] found that the total population of germ cells rose from 600 000 at 2 months to a peak of 7 million at 5 months. Termination of pregnancy should be offered for large lesions with fetal hydrops, if aneuploidy is detected or if there are other major associated anomalies. The impact of this often depends on whether the mother is taking antithyroid drugs. Fortunately, the benefits and hazards of some of these strategies have been evaluated in randomized controlled trials. The cervical changes associated with preg nancy, including ectropion, hyperaemia and friability, increase the risk of spirochaete entry. While technical problems in assays for the C9orf72 hexanucleotide expansions are being resolved (discussed earlier), Rollinson et al. Up to 5% of women will develop preeclampsia in their first pregnancy and although the overwhelming majority of these will have successful pregnancy outcomes, the condition can give rise to severe multisystem complications including cerebral haemorrhage, hepatic and renal dysfunction and respiratory compromise. It is important that healthcare professionals are aware of such symptoms, can advise appropriate treatment and know when to initiate further investigations. Broad based polyps often recur and may need to be formally resected rather than simply avulsed or blindly curetted to reduce this happening. Before pregnancy Patients should defer pregnancy for at least 1 year after transplant, with appropriate and reliable contraception Assessment of graft function Recent biopsy and/or organspecific tests Proteinuria Scr Hepatitis B and C, cytomegalovirus, toxoplasmosis, and herpes simplex status Maintenance immunosuppression: Azathioprine, Cyclosporine, Tacrolimus and Corticosteroids are all acceptable Azathioprine Cyclosporin Tacrolimus Corticosteroids Mycophenolate mofetil and sirolimus contraindicated Comorbidities. Rheumatic heart disease Mitral stenosis Worldwide, mitral stenosis remains the most com mon potentially lethal preexisting heart condition in 90 Maternal Medicine pregnancy. Volumes of breast milk During the first 24 hours of the puerperium the human breast usually secretes small volumes of milk, but with regular suckling milk volumes steadily increase and, by the sixth day of the puerperium, an average volume of 500 mL will be taken by the baby. As discussed previously, it may take the anaesthetic team longer to establish effective regional analgesia. Preventive measures, like hand washing and minimizing exposure from highrisk areas such as nurseries, must be recommended.

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Presents typically over the age of 20 years, and >50% have a firstdegree relative affected. It usually has a small opening in virgins and is only seen as an irregular remnant in sexually active women. These issues are clearly explained by Smith [45], who related the perinatal risks at each gestational week to the appropriate denominators. If left ventricular systolic function is impaired, the left ventricle may not be capa ble of generating a high gradient across the valve, and a low gradient may therefore be falsely reassuring. However, systematic studies of whether non pharmacological therapies for prenatal depression and anxiety disorders reduce the risks from untreated disorders have not been done [1]. Greater understanding of the factors involved in the loss of uterine quiescence may assist in the anticipation and prevention of preterm labour. Intermediate phenotypes in patients with autosomal dominant hyper-IgE syndrome caused by somatic mosaicism. On the other hand, if a patient with a macroprolactinoma is not treated with bromocriptine, the tumour has a 25% risk of expanding during pregnancy. Other factors are also contributing to the increased risk, including increased maternal age, changing ethnicity, and increasing medical complications of pregnancy. Identifying potential confounders allows investigators to design and collect data appropriately, which then has the potential to minimize confounding. It pierces the pelvic floor and then lies flat on its posterior surface using it as support. The aim is to achieve delivery before irreversible fetal damage, and to wait until severe acidaemia occurs in order to justify intervention is illogical if the chance of vaginal delivery is remote and the fetal condition is already deteriorating. Endometriosis affects approximately 176 million women of reproductive age worldwide [2]. The leading edge of the placenta is often best assessed using a trans vaginal approach, particularly if the placenta is posterior, as the leading edge may be masked by the sonographic signal returned from the presenting part, particularly if the fetus is cephalic [17]. A comparative review of open and closed techniques found a higher risk of bowel injury with the open technique and the risk of vessel injury was so low that no difference was observed [49]. Although there is no increase in pulmonary capillary wedge pressure, serum colloid osmotic pressure is reduced. This is associated with a significantly increased risk of maternal and perinatal adverse outcomes in such pregnancies. Lack of knowledge of resuscitation (both basic and advanced) among healthcare professionals caring for maternity patients has repeatedly been highlighted [27]. The mother should be kept warm, well hydrated and oxygenated and prolonged labour avoided. While the first demands public health action to ensure that all patients have the option to obtain firsttrimester ultrasound dating confirmation, widespread adoption of this practice seems limited at this point. Especially in the developed world, this is associated with assisted reproduction increasing the rates of multiple pregnancy and an increased tendency to obstetric intervention. Childhood morbidity Neurodevelopmental sequelae of prematurity present during the first 5 years after birth and include cerebral palsy, poor cognitive performance and sensory impairments (visual and auditory deficits). Bimanual examination can provide critical information that impacts on investigation and management. Doppler assessment of the maternal uterine circulation is considered to be a promising test. Caudal regression, a rare malformation, has the strong est association with diabetes, occurring roughly 200 times more frequently in infants of diabetic mothers than in other infants [76]. There was a smaller protection against respiratory tract infections but not against other illnesses. Epithelial cords then grow into the mes enchyme (primary sex cords) and the gonad now pos sesses an outer cortex and an inner medulla. They are lined by columnar epithelium and cilia which, together with the peristaltic action of the surrounding smooth muscle, propel the fertilized ovum towards the uterine cavity. Guidelines have been refined to ensure that the use of ultrasound to make a diagnosis of miscarriage based on measurements of the gestation sac or embryo are safe.

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Where there is a history of complete miscarriage, 45% of patients will show ultra sound evidence of retained products and up to 6% will have an ectopic pregnancy [9]. Standard quadruple antituberculous therapy with isoniazid, rifampicin, ethambutol and pyrazinamide is effective but surgical intervention may be required for extensive disease. Furthermore, postterm pregnancy is easily preventable by delivery of the neonate by induction of labour. The grief following the death of a baby may be different from other types of bereavement. Further details of prenatal diagnosis of fetal structural anomalies is discussed in Chapter 20. Patients who are systemically unwell should be advised to rest and should be prescribed adequate analgesia. As placental dysfunction increases, there is increas ing impedance in placental vessels. The perineum should be inspected daily if there has been any trauma and the episiotomy or other wounds checked for signs of infection. It may be particularly difficult for a young woman to accept the need to take oestrogen preparations that are clearly labelled as being intended for older postmenopausal women while at the same time having to come to terms with the inability to conceive naturally. Antecedents and outcome of very early neonatal seizures in infants born at or after term. Prognostic markers and longterm outcome of placentalsite trophoblastic tumours: a retrospective observational study. Across the world, changes in lifestyle and diet are contributing to increasing rates of gestational diabetes and hypergly caemia in pregnancy and we face a global epidemic of macrosomia and its sequelae [74]. These symptoms may not be typical vasomotor in nature and include mood distur bances, loss of energy and generalized aches and pains. Macrosomia is associated with stillbirth and birth injury (shoulder dystocia, brachial plexus injury and limb frac ture) as well as increased rates of operative delivery and perineal trauma [71]. In continental Europe it is common practice to perform a vaginal assessment of cervical length at each antenatal consultation, although multicentre trials have shown that this policy is of no benefit in predicting the risk of preterm delivery. Unlike the Simple Rules, risk prediction models require the use of a computer, an application for smartphone or a calculator integrated in the ultrasound device to acquire the result. At birth the vulva and vagina are well oestrogenized due to the intrauterine exposure of the fetus to placental oestrogen. Pregnancy should be deferred for 1 year after liver transplantation, and women who have had a transplant and are planning pregnancy should be advised to change mycophenolate to an alternative immunosuppressant. Significant degrees of asynclitism can result in labour dystocia and a higher risk of operative delivery [1]. In one study, pregnancy anxiety was the strongest predictor of alcohol consumption in the prenatal period. One widely excepted hypothesis is that progesterone may act as an antiinflammatory. Operative hysteroscopy Hysteroscopic surgery has a number of welldefined indications and these are itemized in Table 37. Other complications can occur to all women who are pregnant at that week of gestation, both those delivering as well as those who remain pregnant. Some researchers have suggested that this could be used to define a cohort of women that should be offered an elective caesarean section, but others believe that the predictive value of the test is not sufficient to merit such significant intervention. Markers of bone formation and breakdown can be useful in that changes occur more rapidly than with bone density, but their use is largely confined to research. Maternal homeostatic responses All the normal physiological adaptations, such as increased cardiac output, glomerular filtration rate and renal blood flow, are further increased in a multiple pregnancy. A short or weak cervix may therefore contribute to preterm delivery not only by leading to simple secondtrimester miscarriage but also by contributing to a risk of ascending infection leading to a more classical spontaneous preterm labour. Ideally, they will be referred to a dedicated multidisciplinary service and the majority will require consultant led care. Identification of 9alpha,11betaprostaglandin F2 in human amniotic fluid and characterization of its production by human gestational tissues.