It is often lumped together with other non-chemical, non-biological forms of damage under the heading of physical damage, which includes extremes of temperature and the various forms of radiation. In most cases there are no symptoms, but sometimes there may be a feverish illness that resembles infectious mononucleosis. Regular antenatal exam inations will detect m edical conditions com plicating pregnancy at an early stage o their developm ent, but it is uncertain i this will reduce the incidence o preterm birth. If the rst twin presents as a breech it is com m on practice to perform a caesarean section. During this tim e, attem pts should be m ade to discover any psychological upsets that m ight have precipitated the pruritus. As candidal infection of the vulval skin is com m on, vulval skin scrapings should be taken in cases where general diseases and allergic causes have been elim inated. Carbam azepine is considered to be the safest drug, although it has been associated with a sm all increase in the risk of spina bi da, and so additional prophylactic folate therapy is im portant. This problem could lead to a rise in the incidence of skin cancer and cataracts, as well as having other potentially hazardous effects. Endicott J, Nee J, Harrison W 2006 Daily Record of Severity of Problems: reliability and validity. Treatm ent is dif cult, but frequent sm all m eals, avoidance of spicy food, alcohol and cigarettes, and the use of antacids m ay relieve the discom fort. Each bud contains about 25 sensory receptor cells, with tiny taste hairs that respond to food and drink. The involuntary m uscle that form s the bladder can be divided into two parts, that form ing the fundus, which is poorly supplied by autonom ic nerves, and that form ing the base (the detrusor m uscle), which is richly supplied by autonom ic nerves. Nevertheless, patients should be aware that the rare possibility of a laparotomy and longer hospital stay does exist. Removable appliances, consisting of a plastic plate with attachments that anchor over the back teeth, are used when only one or a few teeth need correcting. Specific learning difficulties include dyslexia, dyscalculia (the inability to solve mathematical problems), and dysgraphia (writing disorders). Herbs may contain many chemical compounds, the individual and combined effects of which are unknown. Rarely, prolonged use may reduce blood cell production; regular blood counts are therefore carried out during treatment. Low weight gain increases the risk of sm all for gestational age babies and dif culties with initiating breastfeeding, and high weight gain is associated with high birth weight, m aternal hypertension and pre-eclam psia and neonatal m etabolic disorders. Serum progesterone Progesterone, a C-21 hormone, is essential in early pregnancy for decidual function, implantation, reduction in immune response and myometrial quiescence. The most effective treatment is frequent use of artificial tears (see tears, artificial). Injury to a cell results in relative disruption to one or more of these structures or functions. When these changes become so severe that they cannot be reversed, cell death occurs. In m ost cases, a cephalosporin or am oxicillin is appropriate initial treatm ent. So, too, can focusing on nearby objects; sufferers should look at a point on the horizon. The urine collects in the renal pelvises and is then passed down the ureters into the bladder by the actions of gravity and peristalsis. Urge incontinence and urethral sphincter incontinence can coexist, and urodynam ic studies allow an assessm ent o which is dom inant and hence whether treatm ent should be prim arily m edical or surgical. Inadequate dietary iron intake and gastrointestinal blood loss (hookworm infestation) are the com m onest causes of iron de ciency.
Surgery is indicated i the drug treatm ent ails in the presence o obvious abscesses that do not respond to antibiotics. Barbiturate drugs, phenytoin, oral contraceptives, and tetracyclines precipitate attacks. A patient diagnosed with active tuberculosis in the rst half of pregnancy should be treated with isoniazid and etham butol. Mongolian blue spots are patches of slate-blue discoloration over the sacrum or lower spine; they occur particularly in Asian infants. Yaws is caused by a spirochaete (a spiral-shaped bacterium), and it spreads principally in conditions of poor hygiene. Jurkovic et al (1992), in a prospective study, used colour Doppler to detect and compare changes of blood flow in the uterine and spiral arteries and the corpus luteum in ectopic and intrauterine pregnancies. Minimally invasive surgery may be used for many operations in the abdomen (see laparoscopy), including appendicectomy, cholecystectomy, hernia repair, and many gynaecological procedures. In general there is no advantage to a parasitic organism in damaging the host, and most organisms that have parasitised man for a long historical period show reduced aggression and the hosts show some degree of tolerance. A few m en develop scrotal swelling, bruising or a sm all haem atom a, all of which settle quickly. The cells m ay secrete oestrogen or be relatively quiescent, and because of this the sym ptom s vary. In uncircumcised babies, some degree of phimosis is normal, but it usually improves by age 3 or 4. It may be caused by injury to the nail, and may also be associated with iron-deficiency anaemia or lichen planus. The wom an in the exam ple given in this designation would bleed for 5 days every 25 days, which is norm al. The um bilical cord should be replaced in the vagina to reduce the risk of cold causing spasm of the um bilical vessels. The condition is probably due to a lack of adaptation to progesterone-induced hyperventilation. It may be confined to an area of the lung affected by a condition such as pneumonia or tuberculosis, or it may be widespread through the lungs (see fibrosing alveolitis). The perinatal period is often defined as the period from the 28th week of pregnancy to the end of the 1st week after birth. There is rarely any need for an urgent hysterectomy and, once the operation has been recom m ended by a gynaecologist, it m ay be helpful for the wom an to talk with her general practitioner about the bene ts of and problem s related to the operation. The major advantages of direct injection of methotrexate into the tube include smaller dose of the drug, higher tissue concentration and fewer systemic side-effects. The arm is immobilized in a cast, with the elbow at a rightangle, until the fracture heals. The distended oviduct has a thin wall, which is translucent and usually retort-shaped. Endom etrial polyps, subm ucous broids and intra-uterine adhesions and septae can be rem oved and the endom etrium ablated (see p. Each of the categories above is subtyped on the basis of the medical history, physical examination and laboratory tests as: (A) lifelong vs acquired; (B) generalized vs situational; or (C) aetiology (organic, psychogenic, mixed or unknown). Most studies report cut-off concentrations of less than 16 nmol/l for failing pregnancies and more than 80 nmol/l for healthy ongoing pregnancies (Mathews et al 1986, Sau and Hamilton-Fairley 2003, Bishry and Ganta 2008). They will generally not arrest early in the circulation since the veins increase in diameter with the direction of blood flow as they approach the lungs, and only then do they start to turn into progressively smaller vessels of the lung bed. The cause is unknown, but various factors are involved, including air conditioning, passive smoking, lack of natural ventilation and light, and psychological factors. This causes the norm al acidity of the vagina and explains the relative resistance of the vagina to infection. Each hip bone consists of 3 fused bones: the ilium (the largest and uppermost), ischium (which bears much of the body weight when sitting), and pubis (the smallest). The sym ptom s vary in character and tend to becom e worse as m enstruation approaches. In many cases, another part of the spine curves to compensate, resulting in an S-shaped spine. Weight reduction should be encouraged in overweight and obese women with a body mass index above 25 kg/m2 prior to starting medical treatment.
A deep vein thrombosis 549 is not necessarily serious in itself, but part of the clot may break off and travel in the bloodstream to the lungs. Often, however, chronic inflammation occurs as a primary event, there being no preceding period of acute inflammation. If her partner has sexual problems, the woman can feel hurt and rejected, and will frequently blame herself, presenting at a clinic for help in solving the problem. Statistics about the prevalence of rape are dif cult to obtain, as fewer than one third of rapes are reported, but about one wom an in 200 has been raped or suffered attem pted rape in any one year. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic. Other likely factors include smoking and alcohol intake; diet may also play a part, in particular eating large amounts of salted or pickled foods. Pubic, facial, axillary, and other body hair appears, the voice deepens, and muscle bulk and bone size increase. If temporal arteritis is suspected, a biopsy may be performed on an artery at the side of the scalp. The cervix is fully dilated, and the head is beginning to rotate at the level of the ischial spines. Apart from "innocent" murmurs, the most common cause of extra blood turbulence is a disorder of the heart valves. Rhesus incompatibility is now uncommon because injections of anti-D(Rh0) immunoglobulin are given routinely to Rh-negative women during pregnancy and at delivery. The minipill works mainly by making the mucus lining of the cervix too thick to be penetrated by sperm. Although they are usually harmless, an unsightly growth, 361 or one suspected of being skin cancer, can be removed surgically. Studies have consistently shown that evidence is lacking to support this hypothesis. The sensory bres then pass 360 Chapter 4 3 Anatomy of the fem ale genital tract Para-aortic nodes External iliac nodes Internal iliac nodes Sacral nodes Parametrial node Obturator nodes Superficial femoral node. As 50% will develop gestational hypertension or pre-eclam psia, these wom en require ongoing surveillance during their pregnancy. Diagnosis is made with a chest X-ray followed by pleural biopsy or examination of a fluid sample from any effusion. The main disadvantage of blind sampling of the uterine cavity is that pathology such as polyps or submucous fibroids may be missed. Hence, sonohysterography has been used to evaluate the endometrial cavity for polyps, submucous fibroids and uterine abnormality, especially septate and subseptate uterus. A symmetrically enlarged uterus is more typical of adenomyosis or endometrial carcinoma. Ge ne ral dise ase s the m ost com m on general disease causing pruritus vulvae is diabetes m ellitus. Unimodal somatosensory association area (Brodmann area 5): Involved in recognition of object shape by tactile sensation stereognosis Subcortical afferents: anterolateral system/spinothalamic tract, dorsal columns, and trigeminal pathways terminate in the ventroposteromedial and ventroposterolateral thalamic nuclei that then project to the primary sensory cortex C. Inadequately treated hypothyroidism increases the risk o in ertility, preeclam psia, growth restriction, prem ature birth, placental abruption and etal death. Other possible causes of vulvitis include allergic reactions to hygiene products, excessive vaginal discharge, or urinary incontinence. Otoscopy (examination using an otoscope) is performed to detect physical abnormalities such as inflammation or pus in the outer-ear canal (see otitis externa) and distortion or rupture of the eardrum. Perceived by abdominal palpation 20 10 mmHg 10 0 Abdominal pressure 0 50 50 100 200 s 1 2 3 Pain 25 mmHg 4 5 Time (min). The father of the child or a signi cant other person rem ains with the wom an in labour, providing support.
Treatment may be by surgical removal of the tumour, radiotherapy, hormone replacement, or a combination of these techniques. At the same time as the formation of granulation tissue the process of inflammation is beginning with an influx of various plasma constituents leaking from damaged vessels and adjacent intact vessels which have dilated in response to the various local mediators of inflammation (Chapter 2) released by the trauma itself (Table 1. There are 13 vitamins: A, C, D, E, K, B12, and 7 grouped under the vitamin B complex. If a stroke is proven by scan to be due to thrombosis, thrombolytic drugs may be given. Trichinosis may be suspected from the symptoms, and the diagnosis is confirmed by blood tests, or by a muscle biopsy. This reaction is reduced if the parents touch and hold the infant for as long as they wish; if keepsakes are available, including a lock of hair and a photograph; and if a health professional is readily available if the parents want m ore inform ation. The m ost com m on vulval problem is lichen sclerosis, which presents with chronic pruritus, pain and dyspareunia if there is ulceration and ssures. These changes occur because the am ount of circulating oestrogen falls to a very low level. Treatment includes keeping the child warm and giving a high-energy, proteinrich diet. The normal range is shown in pink; levels found in trophoblastic disease are shown in the blue area. Abnormalities on pelvic examination should be investigated by ultrasound, and laparoscopy if required. By the 22nd gestational week a capillary system has developed and the lungs are capable of gas exchange. The pathology of an endom etrial sam ple m ay show sim ple (cystic) endom etrial hyperplasia. If pus develops in the infected area, causing a breast abscess, incision of the abscess and drainage for 24 hours m ay be required. Maternal mortality rate describes the number of such deaths per year per set number of pregnancies. Early-first-trimester abortion (9 weeks) Surgical Vacuum aspiration has been the method of choice for early surgical termination of pregnancy in industrialized countries for over 20 years. The tips of the vaginally located ngers are placed in each lateral fornix in turn and then pushed backwards and upwards as far as possible without causing pain. Radiotherapy and anticancer drugs may be used in addition to or instead of surgery. The wom an is then free to am bulate and is assessed 6 or so hours later, unless she goes into labour or the m em branes rupture. Although endom etriosis is associated with in ertility, whether it is a cause o in ertility is disputed, unless the lesions are severe and distort the anatomy. It appears to have no significant effect on gonadotrophin secretion in women, and therefore androgens do not increase during treatment, unlike the effect in men in whom androgens rise since they regulate gonadotrophin secretion. The usual complaints are abdominal pain, bleeding, neurological symptoms, rashes, and fever. Treatm ent consists of correcting the dehydration and prescribing appropriate antibiotics, having tested for bacterial sensitivity. Possible side effects include drowsiness, clumsiness, dizziness, excitement, and confusion. Tibolone conserves bone mass and reduces the risk of vertebral and non-vertebral fracture. A yolk sac or an embryo is rarely seen and the appearances usually lag in comparison with the gestational age (Comstock et al 2005). The wom an m ay be concerned that her partner has been or is continuing to be unfaithful.
Diseases
During development, the sac decreases proportionately in size to the body, reducing finally to a narrow duct that passes through the umbilicus. During this tim e the breasts of som e wom en becom e engorged, as described earlier. The con guration of the posterior fontanelle perm its the occipital bone to be displaced under the two parietal bones during childbirth, thus reducing the volum e of the fetal skull. The infant m ay have slanting eyes with epicanthic folds, short hands, sm all ngers, sim ian creases of the palm s and increased spacing between the rst and second toes; the head is attened at the back, the neck short and webbed. For a tumour in the upper rectum, the affected area and the last part of the colon are removed and the 2 free ends of the intestine are sewn together. The seedlings grow very slowly but pro gressively (over years rather than m onths), under the 297 Fundam entals of Obstetrics and Gynaecology Pedunculated subserous Submucous Subserous Broad ligament Pedunculated Cervical 70% Intramural. After a few days, the cough becomes more persistent and severe, especially at night. The symptoms of neuropathy depend on whether it affects mainly sensory nerve fibres or mainly motor nerve fibres. Foreign bodies induce a chronic granulomatous reaction (Chapter 2) with typical foreign body giant cells. It would be wise to encourage such wom en to have m am m ogram s regularly rom the age o 40. Orthognathic surgery is used to treat severe recession or protrusion of the lower jaw. There is no treatment for the other form, although the affected person may benefit from aids such as magnifying instruments. The muscular stomach wall produces rhythmic contractions that churn the food and gastric juice to aid digestion. The main features of the illness are bouts of coughing, often ending in a characteristic "whoop". Misoprostol is used to prevent and treat peptic ulcers associated with use of nonsteroidal anti-inflammatory drugs. Measurem ent of the peak systolic velocity in the m iddle cerebral artery and interpretation of the result using gestation speci c charts allows prediction of fetuses at risk of m oderate to severe anaem ia. Because the piston can move freely, it can transmit sound vibrations to the inner ear. Bound to these sites, it induces the production of fetal im m unosuppressor cells. Some types are used to correct the position of the uterus (see uterus, prolapse of); others are used as contraceptive devices. Nerve fibres, known as axons, are the filamentous projections of many individual neurons (nerve cells). The fetus is protected by the placenta in m ost cases, although large num bers of im m obilized parasites m ay be found in the placenta, particularly if the infection is by Plasmodium falciparum. Some viruses, such as those responsible for viral hepatitis, yellow fever, and poliomyelitis, are transported in the bloodstream. This is seen in pseudomembranous colitis due to Clostridium difficile colonisation of the bowel, usually following broad-spectrum antibiotic treatment (Chapter 17). Its im portance in childbirth is that it is frequently dam aged during the birth of the baby. Among specific causes are diabetes mellitus, dietary deficiencies, excessive alcohol consumption, and metabolic upsets such as uraemia. The spleen is a fist-sized, spongy organ in the upper left abdomen behind the lower ribs. Halbriech U, Backstorm T, Eriksson E et al 2007 Clinical diagnostic criteria for premenstrual syndrome and guidelines for their quantification for research studies. I the tenderness and pain is severe and the above treatm ents have been tried, the wom an m ay choose to try a horm onal approach. These regim ens induce an abortion in 90% of patients and m ay replace dilatation of the cervix and uterine evacu ation using sponge forceps and a curette, which can be a bloody and prolonged procedure. A fault in the fetus m ay be anticipated if an abdom inal exam ination in late pregnancy reveals a large fetus whose head has not entered the m aternal pelvis.
Any contacts of an infected person are traced and examined, and, if infected, are treated early to reduce the risk of the infection spreading. Propagation is by subsequent crystal deposition which may be affected by a lowering of calcification inhibitors and the presence of free collagen. Currently there are no effective m anagem ent strategies to reduce transm ission, including caesarean section and the avoidance of breastfeeding. When uric acid excretion is disrupted, for example by kidney disease, it may result in hyperuricaemia. A skin graft is often used in the treatment of burns or sometimes for nonhealing ulcers. They have little phagocytic activity, but appear to be adapted to a secretory function. There is usually an abnormal channel (tracheoesophageal fistula) between one of the sections and the trachea. Antibody coated red cells are rem oved from the circulation by the fetal liver and spleen resulting in anae m ia. The Royal College of Obstetricians and Gynaecologists (2004) issued guidelines for the management of tubal pregnancy. It is also prescribed to prevent emboli from developing on replacement valves (see heart-valve surgery). What is happening here is that energy-dependent processes are triggered by the initial ischaemia but they can only occur in the presence of adequate oxygen levels. Depending on the severity of the problem, a child with general learning difficulties may need to be educated in a special school. This group includes the endorphins, which are used by the brain to control sensitivity to pain. Schizophrenia may begin insidiously, with the individual becoming slowly more withdrawn and losing motivation. In addition it increases free androgen index by suppressing hepatic synthesis of sex horm one-binding globulin and by stim ulation of adrenal androgen secretion. Possible side effects include nausea, vomiting, diarrhoea, worsening of kidney disorders, rash, and itching. Periapical periodontitis results from neglected dental caries and occurs when bacteria enter the tooth pulp and spread to the root tip, sometimes causing a dental abscess, granuloma, or cyst. When performed deliberately by pinching the nose and holding the mouth closed, the manoeuvre can prevent pressure damage to the eardrums (see barotrauma). Miscarriages later in pregnancy may be caused by genetic disorders, cervical incompetence, a defect in the uterus, or large uterine fibroids. The technique is Adjustable table also used to detect disorders that affect only the function of organs. Sex-change operations are performed on transsexuals (see transsexualism) and on infants whose external sex organs are neither completely male nor female (see genitalia, ambiguous). The nephrons filter blood under pressure and then selectively reabsorb water and certain other substances back into the blood. They may also indicate an underlying medical problem, such as the rashes of scurvy or pellagra, which are caused by vitamin deficiency. Furthermore, oral treatment, but not vaginal treatment, with low-potency formulations (such as oestriol) increases the relative risk of endometrial neoplasia. Weight loss Weight loss, due to negative nitrogen balance, is common when there is extensive chronic inflammation. Telangiectasia is not a cause for concern, but the veins can be removed in some cases by electrodesiccation (electrical destruction of the upper layers of the skin). Treatment: none specific Prognosis: progressive gait disturbance may ultimately require wheelchair; normal lifespan a. Recently, m ore wom en are reporting that they have been sexually assaulted in childhood or early adolescence, and this can be the basis of a fear of sex and a low sexual drive. The 2 optic nerves each consist of about 1 million nerve fibres that transmit impulses from the retina to the brain. The menstrual cycle length will not be changed by the procedure, and hysterectomy may be an appropriate alternative in women with very irregular bleeding (Lewis 1994).
A tender fixed uterus may suggest endometriosis or pelvic inflammatory disease, whilst fibroids can often be palpated. On the other hand, if ultrasound shows an intra-uterine pregnancy, a concurrent ectopic pregnancy is extrem ely unlikely. Other causes include a bladder tumour, bladder stone (see calculus, urinary tract), urethritis, balanitis, prostatitis, vaginal candidiasis (thrush), or allergy to vaginal deodorants. Except for dantrolene, muscle-relaxant drugs partly block nerve signals that stimulate muscle contraction. A wom an su ering rom septic shock m ay be apyrexial, she will have a rapid pulse, hypotension and warm lim bs. Because the head has to be pulled through the pelvic curve, the m other should be positioned correctly, with her legs in stirrups and her buttocks projecting over the end of the bed. Occlusion also describes eye-patching for amblyopia, and the relationship between the upper and lower teeth when the jaw is shut. A uterine broid is com posed of sm ooth m uscle bundles interspersed with strands of connective tissue, surrounded by a thin capsule (Box 36. Skin reactions can be treated by application of alcohol or calamine lotion; corticosteroid drugs may be prescribed for severe reactions. Laminectomy is performed as the first stage of spinal canal decompression (see decompression, spinal canal). Acute inflammation has local and systemic effects, both of which may be harmful or beneficial. It may involve changing the attitude of the partners towards sex, increasing their understanding of sexual needs, and teaching techniques, such as the sensate-focus technique or pelvic floor exercises, for specific problems. Weight gain, abdominal bloating, oedema of extremities (arms and legs), abdominal swelling and water retention. Typical themes are persecution, jealousy (see jealousy, morbid), love, and grandeur. A skin biopsy shows that the horny layer is unchanged or hyperkeratinized, with thinning of the epiderm is and the disappearance of the rete pegs. Whether the service chooses to screen for genital tract infection, particularly chlamydia, or simply to treat everyone with prophylactic antibiotics will depend on the background incidence of infection in the local population, but one or other is essential. It was found that this configuration was asymmetrical in 84% of intrauterine pregnancies, whereas the endometrium showed asymmetry in 90% of extrauterine pregnancies (P 0. The hinge joint is the simplest, allowing bending and straightening, as in the fingers. At f rst, as each artery penetrates the basal endom etrium it is straight, but in the m iddle and superf cial layers it becom es spiral. Vacuum aspiration can be performed under either local paracervical block or general anaesthesia. When laparotomy is performed, the easiest way to remove the fallopian tube is by progressive division and ligation of the mesosalpinx. With a cardiotocograph linked to a com puter, the area under the contraction can be m easured and expressed in kilopascals per 15 m inutes. Neurotoxins are present in the venom of certain snakes (see snake bites), and 400 are released by some types of bacteria (such as those that cause tetanus and diphtheria). Be nig n the rato ma (de rmo id cyst) Deriving from germ cells, benign teratom ata are relatively com m on. In severe cases, the diarrhoea and bleeding are extensive, and there may be abdominal pain and tenderness, fever, and general malaise. Other factors commonly associated with the occurrence of these ulcers are minor injuries 566 U (such as at an injection site or from a toothbrush), acute stress, or allergies (such as allergic rhinitis). Liver function tests show a characteristic pattern of abnormalities, and liver biopsy may be needed to assess the severity of damage. In ankylosing spondylitis, fusion of the vertebrae may result in permanent neck rigidity. Endom etrial ablation should only be perform ed by a gynaecologist experienced in the technique, or the results will be poor and the wom an m ay be at risk of severe com plications. In som e cases of labour the reverse occurs and the uterus is overactive, leading to a precipitate birth.
The strom al cells react to the invasion by becom ing polyhedral in shape and lled with glycogen and lipid and converting into a decidua, which supplies the energy needed by the invading trophoblast. This is m ore likely to occur in the puerperium rather than later, because the pregnancyinduced dilatation of the renal pelvis and ureters and the relaxation of the bladder m uscle take about 3 weeks to disappear. Tumor location: in children, the atria of lateral ventricle; in adults, the 4th ventricle a. This is absorbed by melanin in 26 Hirsutism and virilization for the first 10 days (the reverse sequential regimen of Hammerstein). The incidence varies am ong ethnic groups; 1% Caucasians, 5% Hispanics and 10% reported in Chile. Since then, there has been much research which suggests that women with dysmenorrhoea have increased uterine activity during menstruation (Novak and Reynolds 1932, Filler and Hall 1970). Wom en can have a prepared participatory childbirth in a norm al hospital delivery room, but for som e it is m ore satisfactory if there is a birthing centre. The counsellor m ust inform, but not in uence, the wom an or her partner, who alone are responsible for m aking the decision whether to term inate or to continue the pregnancy. In recent years a num ber of younger wom en have been presenting with m alignant change in a vulval condylom a. Such spasm is directly induced by cigarette smoke and is particularly common in vessels with some degree of intimal damage such as atheroma. Infants who have required advanced resuscitation or have prolonged cardiorespiratory depression should be closely observed in a special care nursery until it is clear that they have recovered or need continuing specialist care. It occurs because the child is unable to digest food properly, perhaps because of inadequate chewing; the diarrhoea contains recognizable pieces of food. Nonetheless, a consideration of such changes is valuable when compared to the histology of the normal, uninjured, cell. These findings strengthen the argument for increased detection rather than late-stage promotion of breast cancer. Diagnosis may be made from a rectal examination, from proctoscopy, sigmoidoscopy, colonoscopy, or a double-contrast barium X-ray examination. To obtain an accurate diagnosis the chancre is f rst cleaned with a swab, and then, i necessary, its edge and base are scarif ed with a scalpel so that exudate appears be ore the specim en is taken. Periodontal disease in pregnancy occurs in 50% of wom en and is associated with lower levels of education and socioeconom ic status. Treatm ent consists of bed rest on a rm m attress, with the wom an nursed as far as is possible, on one or other side. The condition is harmless and usually disappears spontaneously within a few weeks. A small amount of tuberculin (purified protein from the bacteria) is injected into the skin. In spontaneous conception, the incidence has traditionally been quoted as one in 30,000 pregnancies. Signs of ovulation include a rise in body temperature, changes in the cervical mucus, and sometimes mild abdominal pain (see mittelschmerz). One of the earliest signs of irreversible cell damage is the failure to exclude calcium from cells and from mitochondria; while this may only be an incidental marker of cell damage it is also a very early event in apoptosis and may be an early cellular process actually leading to cell death. Provided pregnant wom en over the age of 35 receive antenatal care, a sound genetic diagnosis and counselling early in pregnancy, the outcom e in term s of a live healthy m other and a live healthy child is excellent. Labour seems to last longer in nulliparous women, particularly older primigravidae, and if the baby presents in the occipitoposterior position. They are most numerous on the scalp, face, and anus and are absent from the palms and soles of the feet. The first line of treatment is a slimming diet (see weight reduction) plus regular exercise. Radioactive leaks from nuclear reactors can cause a rise in mutation rates, which may lead to an increase in cancers, such as leukaemias; to birth defects; and to hereditary diseases. The hot ushes occurring at night lead to sweating and insom nia, with fatigue the next day. In the case of radiation we have the added problem of iatrogenic damage since many medical activities involve exposing the patient to some form of radiation, including both diagnostic and therapeutic modalities.
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