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The vas deferens itself may be occluded, and this is specially to be suspected if there is a herniorrhaphy scar and doubly so if the scar is bilateral. Explain that it is possible to find faulty function in both partners, and often overlapping causes exist, hence the need to evaluate and treat both the partners concurrently. Less severe varieties of this emphysema have been described in which the gas-containing vesicles are found on a routine inspection of the vagina, and these cause minimal symptoms. The principle is employed in gas-mixing devices (including fixed performance oxygen therapy devices), suction equipment, ejector flowmeters, scavenging equipment and devices used to circulate gases round breathing systems. Some clinicians use the term to describe any white or yellowish-white discharge from the vagina. Each utilises a small transducer positioned over a peripheral artery or attached to a digit: microphone or Doppler probe. The vaginal examination should include measuring the length of the cervix, position and mobility of uterus. The cervical erosion results from the extension of the columnar endocervical epithelium beyond the external cervical os to replace the squamous epithelium covering the portio vaginalis of the cervix. For a gas dissolving in a liquid, solubility depends on the temperature (solubility decreases as temperature increases), and the properties of the gas and liquid (expressed by the solubility coefficient). 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. After undercutting the tissues on each side and dividing the superficial muscles of the perineum, the wound is closed by interrupted sutures so that the scar lies transversely. This treatment is also contraindicated in vaginal and cervical lesions because of severe inflammatory reaction provoked at these sites. Useful as a means of comparing different agents, and may be used to guide clinical dosage if end-tidal concentration of agent is monitored. Features include non-specific symptoms (malaise, weight loss, fever, night sweats), nasal discharge and ulceration, pleurisy, haemoptysis, myalgia, arthralgia and renal failure. It is felt as a dull ache in the lower abdomen a few days before menstruation and is relieved following menstrual flow. In a male, gonorrhoea causes urethritis initially, but chronic infection can ascend to cause epididymitis and orchitis and damage the upper genital tract. With women living longer than before, a majority would spend one-third of their life in the postmenopausal stage. Contains the heart, great vessels, trachea, oesophagus, thoracic duct, vagi, phrenic and recurrent laryngeal nerves, sympathetic trunk, thymus and lymph nodes. The procedure is carried out in the operation theatre observing full surgical asepsis. Especially effective against pseudomonas infections, although bacterial resistance is a growing problem. All are G protein-coupled receptors and activation results in opening of potassium channels and closure of voltagegated calcium channels; this leads to membrane hyperpolarisation, reduced neuronal excitability and thus reduced nociceptive transmission. Acupuncture and short-wave diathermy are adjuvants, and are effective in some women. An important condition that is readily confused with stress incontinence is urge incontinence. Diagnostic approach: A history of the nature of bleeding and a general physical examination are essential to begin with. Appropriate investigations such as ultrasonic examination and a pregnancy test will confirm or refute the diagnosis. Grape-like sarcoma of the cervix arises typically in adult women, metastases develop rapidly, and local recurrence follows their removal. The written consent should be obtained from the husband or guardian, as the psychiatric patient may not be mentally aware of the nature of sterilization. Distribution of fat is thought to be more important than weight per se, with abdominal deposition particularly detrimental.

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Oral combined pills are effective in only select women and not safe after the age of 35 years, in smokers and obese women. The uterine arteries may also compress the ureter as they become elongated by the descent of the uterus. This test depends on the presence of oestrogen-primed endometrium in the uterine cavity. The basal layer measures 1 mm in thickness, while the functional layer, commencing with an average of 2. In large tumours, the connective tissue cells are elongated and an intercellular matrix becomes prominent. Smear and culture of the discharge if serosanguinous or purulent bloodstained and offensive are of fundamental importance. Operations for stress incontinence such as Stamey and Pereyra operations leave a hiatus in the vaginal wall causing cystocele and enterocele, while elevating the bladder neck. Carcinoma cervix: In women presenting with local cervical lesions (ulcer, polypoidal growth) clinical findings such as lack of induration, lack of friability should raise suspicion of alternative pathology. The positions of the holes on the valve block (and corresponding pins on the yoke) are specified by an international standard. Separation of the labia reveals a mulberry like protrusion at the site of the urethral orifice. Haematometra Haematometra, caused by cervical stenosis, causes enlarged uterus and secondary amenorrhoea. Hypotension may be exacerbated by bradycardia and sedative drugs (depressant effects of local anaesthetic are minimal). Rare disorder characterised by intravascular thrombosis, consumptive thrombocytopenia and haemolytic anaemia (due to mechanical damage to red cells). Most physiological changes occur in response to the increased metabolic demands of the uterus, placenta and fetus, and include alterations in the following systems: cardiovascular: - increased intravascular volume from the first trimester, returning to normal within 2 weeks of delivery. This complication of uterine myomas develops most frequently during pregnancy, although it is not rare in cases of painful myomas in women over the age of 40. Intrauterine device and progestogen-only pills cause irregular bleeding and are best avoided. Place a drop of the mixture on a slide, cover it with a cover slip, warm the slide and examine it under the low power of the microscope. Clinical Features It begins as a painless nodule which later ulcerates to form multiple beefy red painless ulcers that tend to coalesce, the vulva is progressively destroyed and minimal adenopathy may occur. This condition is due to several causes that make the standard methods of investigations and management inconsistent and difficult. The islands of lymphoid tissue in the basal layer of the endometrium scatter lymphocytes into the functional layer so that at this stage, there is a well-marked lymphocytic infiltration of the whole of the endometrium. Basic pathways may be discussed in terms of dietary substrate: carbohydrates: digested to monosaccharides, absorbed and passed to liver and muscle. Frequency of micturition is one of the most common symptoms complained of by gynaecological patients, and although many causes of frequency lie in the urinary tract, a large number are gynaecological. Complications: hypoxaemia: may be related to rapid removal of airway gases, causing atelectasis, bronchospasm/ coughing or disconnection from the ventilator. The mucous polypi should be regarded as being produced by hyperplasia of the mucous membrane of the cervical canal which becomes thrown into folds and finally one of the folds, projecting into the cervical canal, assumes the characteristics of a polypus. May also involve direct impulse conduction between medullary respiratory and cardiac neurones. Note that the almost vertical direction of the uterosacral ligament must follow from the cervix to the junction of the second and third sacral vertebrae. They correspond developmentally to the gubernaculum testis and are morphologically continuous with the ovarian ligaments, as during intrauterine life the ovarian and round ligaments are continuous and connect the lower pole of the primitive ovary to the inguinal canal. Also reduced in the elderly, and in patients with restrictive lung disease, muscle weakness, abdominal swelling and pain.

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May be involved in the development of certain behavioural aspects of pain syndromes. The body weight increases by 1 kg and breast volume by 20% due to oedema and increased vascularity. Semisynthetic penicillin derivative with broad-spectrum antibacterial activity; has greater activity against Gram-negative organisms than narrowspectrum penicillins, with slightly reduced effectiveness against certain Gram-positive organisms. Treatment When a woman comes in the process of abortion, vesicles can be identified amongst the products passed. Ultrasound is also used in certain therapeutic procedures such as in vitro fertilization and aspiration of a cyst or pelvic abscess. Progesterone causes secretory endometrium only if the latter is primed with oestrogen. The ovulation is not suppressed, no menopausal symptoms even if the woman develops amenorrhoea. Tiny intravascular probes have been developed for continuous arterial measurement. Anticholinergic drugs, drugs which sensitise the myocardium to catecholamines and indirectly acting sympathomimetic drugs should be avoided. However, lately, studying ovulation pattern in infertility by endometrial examination has lost considerable importance and is superseded by ultrasonic scanning, which is noninvasive and accurate in detecting the timing of ovulation and the result is available on the spot. The pack originally included a blade, 4 mm internal diameter tube and introducer, standard 15 mm connector, suction catheter and securing tapes. Lately, instead of end-to-end suturing of the torn sphincter muscles, overlap technique is recommended to yield a stronger sphincteric control. Pain Abdominal pain, generally severe, is a consistent feature of ectopic pregnancy in 95% cases. Congenital rectovaginal fistula is rarely seen and is the result of maldevelopment of the lower part of the rectum and anal canal. Prognosis Conservative medical treatment and minimal invasive surgery yield better fertility rate than radical surgery. Flexible hysteroscopy can be directed to all parts of the uterine cavity and extensive inspection is possible. Acute systemic autoimmune disease occurring after infection by certain serotypes of group A streptococci. Women with streak ovaries are infertile, but they can bear children with oocyte donation. For example, urge incontinence is often associated with true cystitis or urinary infection. Sampson observed that in cases of uncomplicated endometriosis, the fallopian tubes were usually patent. Group of idiopathic autoimmune inflammatory diseases, including dermatomyositis, affecting muscle and skin. Contraception for Women Over the Age of 35 Years Women over the age of 35 years constitute 20% of the contraceptive users, and selection of the proper contraception is an essential component of family planning counselling. It is therefore important to rule out cancer by toluidine blue test, colposcopy and biopsy. Other tocolytic drugs include atosiban (an oxytocin antagonist), which is more expensive but has fewer side effects than 2-agonists in preterm labour (although it may cause nausea, vomiting, tachycardia and hypotension). Sensory urgency is an intense desire to void that is not associated with detrusor pressure. Stool examination for amoebiasis, sigmoidoscopy, colonoscopy and barium enema may reveal the cause of abdominal pain. When all possible organic causes of the dyspareunia have been eliminated, psychogenic possibilities must be considered; patient enquiry may then elicit the true cause, such as fear of pregnancy, frigidity, marital disharmony or some unhappy sexual experience in the past.

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Group of corticosteroids; typically comprise aldosterone physiologically and fludrocortisone therapeutically. Pelvic Abscess Pelvic haematocele may be mistaken for pelvic abscess, especially if the patient has fever. Danazol has a limited role when oral contraceptives and progestogens are not suited to a woman. The subclavian vein is the continuation of the axillary vein and arises at the lateral border of the first rib. Cerebral angiography demonstrates an aneurysm in 80% of cases; the anterior (30%) and posterior (25%) communicating arteries, middle cerebral (20%) and basilar (10%) arteries are most commonly affected (see Cerebral circulation). A new course of tablets should be commenced 7 days after the cessation of the previous course. In the long term, these individuals with chronic anovulation are at risk of developing endometrial hyperplasia and malignancy. Membranous dysmenorrhoea is a special group in which the endometrium is shed as a cast at the time of menstruation. It has already been pointed out that the repair of a complete tear of the perineum should be undertaken carefully, with the patient in the lithotomy position and under anaesthesia. Water overload may occur, since the droplets are very small and the water content of the gas is high. In some cases, total abdominal hysterectomy will be desirable if the patient is in the older age group and has completed her family. Routine coagulation studies are more accessible, but less useful for diagnosis: platelet count: low or normal. Regularly lactating women experience a longer duration of amenorrhoea and ovulation is delayed for at least 3 months, or even longer at times (6 months). Other gross congenital abnormalities are present such as coarctation of the aorta. Combined long-acting norgestrel 12 mg with 3 mg quinestrol, two tablets in the first month followed by one tablet each month is under trial. Prolonged tracheobronchial suctioning may cause lung collapse and hypoxaemia; bradycardia is common in critically ill patients. Atropine im does not affect sphincter pressure, but inhibits the action of metoclopramide. A low-pitched rumbling diastolic murmur follows, heard best at the apex on expiration with the stethoscope bell, leaning forward and to the left. In order to make the diagnosis the following must exist: the stressor is considered exceptional. Devices that convert one form of energy to another, usually to electricity in monitoring systems. The isthmic portion stretches during pregnancy and forms the lower uterine segment in late pregnancy. Although platelet dysfunction has been shown after perioperative use, bleeding problems are rare, although care is required if other drugs with anticoagulant actions are co-prescribed. Calcium should be taken in the morning and etidronate swallowed (not chewed) in the afternoon, on an empty stomach with a glass of water in the upright position; stay upright for half an hour. Nutrition from protein, calcium, and iron are required for the growth and maintaining haemoglobin; calcium need increases by 50% and iron by 15%. A functional cyst may be persistent at times, but never grows more than 5 cm and spontaneously resolves within a month or so. The mode of onset pain, its location, severity, duration and radiation to other areas should be inquired into. Equals the time in which the process would be completed if the rate of change were maintained at its initial value.

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• Fanconi anemia type 2
• Acute febrile neutrophilic dermatosis
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• Shellfish poisoning
• PHACE association
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On rare occasions, the effusion may point in the perinephric region, in the ischiorectal fossa and even in the buttock, having tracked through the greater sciatic foramen. Aetiology Endometriosis is a proliferative hormonal dependent disease of the childbearing period. Genital tuberculosis occurs almost always secondary to a primary focus elsewhere, the commonest site being the lungs (50%), but rarely from other sites such as lymph nodes (40%), the kidneys, joints, gastrointestinal tract or as part of a generalized miliary infection. It is to be stressed, however, that this excessive discharge is not necessarily pathologically infected, but could be hormonal. Group of broad-spectrum antibacterial drugs, less commonly used now because of bacterial resistance and side effects. It also improves peripheral utilization of glucose; liver and renal function tests should be performed prior to metformin administration. Ovarian cysts, benign and malignant, pelvic endometriosis and inflammatory disease and broad ligament tumours produce the same picture. A young primigravida presents with 2 months amenorrhoea, slight abdominal pain and vaginal bleeding. During vaginal examination, the body of the retroverted uterus is tender and the patient may wince when it is touched. Urine collects in the vagina, but the woman also micturates, and oliguria is noticed. Systemic venous obstruction and poor long-term right ventricular function have led to increased use of procedures which switch the pulmonary and systemic circulations, at ventricular or arterial levels. Severe lacerations and penetrating injury entering the pouch of Douglas require emergency surgical attention. Changing the anaesthetic machine, tubing and soda lime has been suggested if possible. Another complication that may develop is a rectovaginal fistula which is usually the result of faulty technique but also may be due to infection and breakdown of sutures. The vessels form a longitudinal anastomosis up and down the ureter which protects the ureter from ischaemia if one vessel is ligated or injured. If a woman cannot come for the follow-up, prophylactic chemotherapy is better than no follow-up. Abdominal surgery is elected in young women to avoid coital difficulties, so also in women who develop recurrence following vaginal repair. Depending upon the cause and extension of tear, suturing or hysterectomy is performed. It is also important to realize the futility of repeating the same investigations by different doctors which may be frustrating to the couple apart from the expense incurred. Hence, it cannot be overemphasized that strict monitoring of the amount of glycine used, its input and output must be accurately documented. The uterus is enlarged asymmetrically, and the rounded dark areas consist of spaces full of blood. Side effects: sedation, dizziness, headache, agitation, psychosis, visual disturbances. Activation by sustained or repeated C-fibre stimulation leads to intracellular phosphorylation of proteins and causes opening of specific membrane ion channels (opposed by magnesium). Removes the need for application of downwards force with a rigid dilator, theoretically reducing the risk of injury to the posterior tracheal wall. 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. The idea of endometrial ablation arose from oligomenorrhoea occurring in Asherman syndrome due to synechiae. Side effects (more likely with higher doses): myopathy, myalgia, rhabdomyolysis, abnormal liver function (severe hepatitis rarely), depression, fatigue, skin reactions. Adenomyosis Adenomyosis, also labelled uterine endometriosis, is a relatively common condition in which islands of endometrium are found in the wall of the uterus.

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Inaccurate readings of haemoglobin saturation may occur with pulse oximetry (as the level of methaemoglobin increases, measured arterial O2 saturation tends towards 85% since both oxygenated and deoxygenated forms absorb light equally at 660 nm and 940 nm). Nerve supply: ninth and 10th cranial nerves, with additional nasal innervation via the fifth nerve. Describe the clinical symptoms associated with uterine displacement in modern day practice. In a rare case with recurrent molar pregnancies, pregnancy with her husband should be avoided. The implants suppress ovulation in 50% but the main action is suppressing endometrium. It is kept in situ for 3 weeks and removed for a week, thus bringing about regular menstrual cycles; failure rate is 1. The first to administer an anaesthetic for obstetrics in 1847, using diethyl ether. Sexual precocity is consistent with normal reproductive function, and is not related to early onset of menopause. Adhesions of the ovaries to the vaginal vault causing ovarian residual syndrome, dyspareunia and chronic pelvic pain. William Squire administered the anaesthetic from a glass inhaler made by his uncle, Peter, whilst Frederick Churchill had an above-knee amputation. Pregnancy In some cases of uterine and ectopic pregnancies, the endometrium shows intense adenomatous and hypersecretive activity within the glandular epithelium. The volumes may exceed several litres, leading to the risk of local anaesthetic toxicity and fluid overload. The general condition of the patient should be evaluated to decide on her fitness for surgery. One important cause of dysuria and pain is radiation cystitis, which in severe degrees can cause a small-capacity irritable bladder. These pills have no adverse effect on carbohydrate and lipid metabolism; therefore, they can be prescribed to diabetic women and without expecting any increased risk of myocardial infarct. During the insertion, the outer coil is wound down to keep it in a low-profile position. The loculi contain a serous straw-coloured fluid, which may be blood stained when malignant transformation occurs. Between the genital folds lies the urogenital or anterior part of the cloacal membrane which breaks down to form the labia minora (sixth week). There are no crypts where organisms can comfortably multiply as in the endocervix. Histologically, the disease is characterized by (i) hydropic degeneration and swelling of the villous stroma, (ii) absence of villous blood vessels and (iii) proliferation of both the trophoblastic epithelia to a varying degree. The granulosa layer itself is nonvascular and capillaries cannot be identified in it. It is desirable to have an oxytocin infusion running throughout the procedure to reduce the risk of uterine perforation and bleeding. The external genitalia should be examined, preferably under anaesthesia, when, for example, a vagina may be discovered concealed by fusion of the labia majora. It is also useful in reducing vascularity besides size, preoperatively, and by causing amenorrhoea or reducing menorrhagia, restores the haemoglobin level. Treatment Tetracycline 500 mg and clindamycin 500 mg 6 h for 14 days are found effective. State of reduced consciousness in which verbal contact with the patient may be maintained. The angle at which the vessels meet, and the presence of valves at the junction, may cause difficulty in passing an iv catheter past this point. Side effects include headache, nausea, constipation, dry mouth and blurred vision. A well-differentiated folliculoid appearance has 10% malignant potential while an anaplastic, almost sarcomatous appearance has 65% malignant potential. P5-adult inverted triangular distribution of thick, coarse, dark curly hair spreading out towards the medial aspects of the thighs is evident.

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Graphs displaying the exponential decline in concentration of a substance that is continuously being removed from a system. Biofeedback therapy with electromyelography for pelvic floor muscles and Kegel exercise cures 80% cases. At birth, the ovaries are populated with lifetime complement of eggs located in the primordial follicles, but most of these follicles undergo atresia throughout childhood and only about 400 of these primordial follicles are present during reproductive age. Vulval Neoplasms Fibroma and Lipoma Fibroma and lipoma are rare pedunculated benign growths that need excision. It comprises physical, psychological and behavioural changes not associated with organic lesion (Table 36. Dysaesthetic Vulvodynia Dysaesthetic vulvodynia is a cutaneous dysaesthesia which causes nonlocalized vulval pain, unprovoked constant neurologic pain in the vulva and perianal region. Common Iliac Glands this group is the upward continuation of the external and hypogastric group and, therefore, involved next in genital tract cancer. However, the growth curve in the male child demonstrates the final spurt a couple of years later before plateauing. During the puerperium, acidity of the vagina is reduced and foreign organisms such as coliform bacilli and other pathogens can grow. The unreliability of this method is obvious, but it has the advantage that it costs nothing and it requires no device. Features are related to muscle abnormality and hypermetabolism, but not all may be present: sustained muscle contraction; results from breakage of the normal impulse/contraction sequence (excitation/contraction uncoupling) relating to abnormal calcium ion mobilisation, and is unrelieved by neuromuscular blocking drugs. Oestrogen causes proliferation of epithelial lining, glandular cells and stroma and mitosis. There is no evidence of fetal malformation or increased rate of abortion in those who conceive while on pills. After passing a gastroscope into the stomach, the stomach is inflated so that its anterior wall makes contact with the anterior abdominal wall. When the downstream pressure falls, this gas re-expands into the back bar, thus increasing the concentration of volatile agent within the back bar. In general, differs from adult intensive care by virtue of anatomical and physiological differences between adults and children (see Paediatric anaesthesia) and the range of conditions seen. Knowledge of lymphatic drainage of the pelvic organs is important in staging, removal or radiation of lymphatic metastasis in genital organ malignancies. Urinary Tract Infection, cystitis and bladder stones cause chronic pelvic pain, but are associated with urinary symptoms. Actions are variable, depending on the stage of the menstrual cycle and pregnancy. Similarly, tumours in surrounding structures may move the uterus out of its normal position. It is now accepted that the diaphragm is porous either by reason of minute foramina or via the lymphatics. Thus there is less control than with inhalational agents, which may be removed by ventilation. Assessment of the sympathetic level is difficult; the galvanic skin response has been used. Aetiological classification of precocious puberty: the various causes are as follows: 1. Anaesthetic considerations: pre-existing restrictive lung disorders and postural hypotension. Disadvantages and complications include discomfort, gastric distension, vomiting and aspiration of gastric contents, and pressure necrosis. However, it has been useful for examining the effects of local anaesthetic dosage, concentration and volume independently, and of the addition of adjuncts. The carotid sheath is retracted laterally with the fingers, and a skin wheal raised over the tubercle. Coitus takes place in a normal manner but the penis is withdrawn immediately before ejaculation. Giving oestrogen locally or orally or prostaglandin E (misoprostol) pessary allows this junction to pout out and improves the efficacy of the Pap smear cytology.

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Amongst the predisposing causes of complete tear of the perineum are forceps delivery in the persistent occipitoposterior positions, and extraction of the after coming head in breech presentation. Pap smear should be obtained prior to vaginal examination, because the fingers may remove the desquamated cervical cells and give a false-negative report, lubricant may prevent detection of organisms and any vaginal bleeding during examination may preclude proper visualization of the cervix. Contact tracing, avoidance of sex or barrier contraceptive is necessary to avoid recurrence. Postoperative oedema may cause obstruction to the flow of urine, and pain from the pelvic region may lead to a reflex spasm of the bladder sphincter. Skinning vulvectomy, cryo- and laser ablation and vulvectomy in older women have been employed. Scarred uterus and enlarged uterus more than 12 weeks size form relative contraindications. Examples have included fatal cardiac arrest following disconnection of the breathing system and inadequate immediate postoperative care. Rapid series of ventricular ectopic beats (usually defined as more than three in succession). Term used to describe neurones of the motor pathways, excluding lower motor neurones. Since the blood supply to the pelvic ureter comes from lateral side, the dissection of the ureter should be done on its medial side, and devascularization and ischaemia should be avoided. If the risk is negligible, sterilization provides the permanent method to prevent a pregnancy. The outer fibrous pericardium fuses below with the central tendon of the diaphragm, and above and superiorly with the adventitia of the great vessels. The uterine artery crosses above the ureter in the parametrium where it gives off an important ureteric branch to that structure. Other measures include the following: n n Improve body immunity with antioxidants such as vitamin C and folic acid. The cervix has the same pH as the seminal fluid and is undoubtedly and demonstrably attractive to the spermatozoa. Surprisingly, Mirena is not effective against endometrial hyperplasia caused by tamoxifen. Actions of individual drugs vary depending on whether they affect predominantly - or -receptors, or both. Absorption of the fluid is followed by inhibition of vasopressin secretion and by increased urinary water loss. It is ideal to relieve pain and menorrhagia in premenopausal women who have completed their families. Ximelagatran, a prodrug for melagatran, was extensively investigated as an oral anticoagulant but withdrawn in 2006 following reports of hepatic impairment. Some have reported the breast cancer in a nulliparous woman (25%) who has taken oral contraceptive pills before the age of 24 years for over a period of 4 years. The association with carcinoma of the cervix and breast cancer in the same woman indicates the common aetiological factors. Acute pancreatitis is an autodigestive process caused by unregulated activation of trypsin in pancreatic acinar cells; this in turn leads to release of other enzymes and activation of complement and kinin pathways. It is now generally accepted that though a spermatozoon after ejaculation may remain motile for a long period, its useful life span is limited to 24 h, and after this short interval, it is less capable of performing its biological duty. A combination between the middle and lateral sacral and lateral lumbar venous system and the vertebral the Glands of the Parametrium the hypogastric group (internal iliac glands) contains all the regional glands for the cervix, the bladder, the upper third of the vagina and also the greater part of the body of the uterus. May cause nausea and dizziness; it is otherwise relatively safe with minimal side effects, although maternal arterial desaturation has been reported, especially in combination with pethidine. The ilioinguinal nerve, derived from L1, and the genital branch of the genitofemoral nerve (L1 and L2) supply the mons, the upper and outer aspect of the labia majora and the perineum.