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By: S. Curtis, M.B. B.CH. B.A.O., Ph.D.

Clinical Director, William Carey University College of Osteopathic Medicine

The fetus then has to negotiate the birth canal hiv infection rate ghana cheap medex express, propelled by contractions of the uterus anti viral enzyme buy discount medex 1mg online. The angle varies between individuals and between races; for exam ple hiv infection stories gay medex 5mg cheap, black Africans have a lesser angle hiv infection unaids order 1mg medex visa. The true pelvis is cylindrical in shape, with a bluntly curved lower end, and is slightly curved anteriorly. Laterally its walls narrow Labour and childbirth is the process whereby the fetus and placenta are expelled from the uterus by coordinated myom etrial contractions. The reason why labour starts rem ains obscure in spite of m uch research and m any theories. When this is elucidated it should be possible to prevent prem ature labour, with its increased perinatal m ortality and m orbidity. For labour to com m ence two things have to occur: the onset of coordinated uterine contractions and the softening of the uterine cervix. In these cases delay m ay occur and the soft tissues of the perineum m ay be torn and dam aged. Facto rs inf ue ncing pe lvic shape and size Minor alterations in pelvic shape have been found in m any wom en receiving routine radiological pelvim etry, but only in a few instances has the abnorm ality been found to delay the birth. Sm aller wom en tend to have a sm aller bony pelvis, but also tend to have sm aller babies. More severe alterations occur in populations where rickets or osteom alacia are found, but are uncom m on in the developed countries today. The walls are penetrated by the obturator foram en anteriorly and the sciatic foram en laterally, which is divided into two parts by the sacrospinous and sacrotuberous ligam ents. The zone of the m idpelvis passes through the apex of the pubic arch, the spines of the ischia, the sacrospinous ligam ent and the tip of the sacrum. If this zone is contracted the fetal presenting part m ay not be able to rotate and m ay becom e arrested. Upper uterine segment this portion of the uterus consists of the fundus and that part of the uterus lying above the re ection of the vesicouterine fold of peritoneum. During pregnancy it undergoes the greatest degree of myom etrial hyperplasia and hypertrophy. In labour it provides the strong contractions that push the fetus along the birth canal. L5 Brim of true pelvis Inlet Ischial spine Cavity Midpelvis Sacrospinous ligament Sacrotuberous ligament O utlet O bturator foramen. Lower uterine segment this portion of the uterus lies between the vesico-uterine fold of the peritoneum superiorly and the cervix inferiorly. During pregnancy the upper part of the cervix is incorporated into the lower uterine segm ent, which stretches to accom m odate the fetal presenting part. In late pregnancy, as the upper segm ent m uscle contractions increase in frequency and strength, the lower uterine segm ent develops m ore rapidly and is stretched radially to perm it the fetal presenting part to descend. Cervix uteri In late pregnancy the cervix becom es softer because of chem ical changes in the collagen bres, and shorter as it is incorporated into the lower uterine segm ent. At the 34th gestational week the cervix is 2 cm or m ore dilated in 20% of prim igravidae and in 40% of m ultigravidae, and the proportion increases towards term. At the onset of labour the cervix of a prim igravida is ripe, and is either partly, or not, effaced. Fo rmatio n o the birth canal during labo ur When myom etrial contraction and retraction have led to full dilatation of the cervix the fetal head descends into the vagina, which expands to encom pass it. Norm ally an apparent space, the vaginal m uscle has hypertrophied and the epithelium becom es folded during pregnancy so that it can accom m odate the fetus without dam age. As the fetal head descends it encounters the pelvic oor and the leading point is directed forwards by the gutter form ed by the levatores ani. Upper uterine segment Lower uterine segment Placenta External cervical os Vagina. Lambdoid suture Posterior fontanelle Parietal bone and eminence Sagittal suture Anterior fontanelle Frontal bone Frontal suture Occiput Biparietal diameter 9. The levator m uscles stretch and are displaced downwards and backwards, so that the anus receives the full force of the descending head and, dilating, gapes widely to expose the anterior rectal wall. Pressure is also exerted on the lower part of the vagina and the central portion of the perineum, and as the head is born the tissues m ay tear. The descent of the fetus from the uterus and out into the world is straight to the level of the ischial spines; it then m oves in an anterior curve around the lower border of the sym physis pubis. If the pubic arch is wide, the head will stem close behind the sym physis and the perineum will not be so stretched. If the angle is narrow the head is forced back, the direction of the curve is m ore obtuse and perineal dam age is likely.

Syndromes

Other angiom ata include port wine stains hiv yeast infection in mouth effective 5 mg medex, which tend to be perm anent antiviral aids order 1 mg medex fast delivery, although som e m ay be am enable to laser treatm ent natural factors antiviral echinamide purchase medex cheap online. Those on the forehead m ay be associated with underlying angiom atous m alform ation on the brain surface hiv infection during pregnancy buy discount medex 1mg on line. Mongolian blue spots are patches of slate-blue discoloration over the sacrum or lower spine; they occur particularly in Asian infants. Between 1 and 3% of neonates show evidence of instability of the hip at birth, but in m ost cases this resolves spontaneously within a week or two. Any suspicion of congenital dislocation or subluxation of the hip is referred for an ultrasound exam ination; if con rm ed, treatm ent is placem ent of the hips in abduction under specialist orthopaedic supervision. Failure to descend by 6 m onths of age should prom pt referral to a paediatric surgeon because of the increased risk of im paired sperm atogenesis and testicular cancer in later life if the testis rem ains undescended. Hypospadias is a defect of closure of the urethra in m ales, with the opening of the urethra being at a variable point along the underside of the penis. Early referral to a paediatric urologist is required; under no circum stances should circum cision be perform ed, because the residual foreskin is required for the repair of the urethral defect. While m any of these resolve spontaneously postnatally, it is vital that all have paediatric follow-up to exclude persistent obstruction due to pelvi-ureteric stenosis. Urethral valves m ay present in utero with oligohydram nios due to severe urethral obstruction; but less severe obstruction m ay present postnatally with poor urine stream, enlarged bladder and/or urinary infection. Atresia of the kidneys is rare and fatal, presenting antenatally with oligohydram nios. Ectopia vesicae due to defective cloacal closure is also very rare and requires com plex surgical repair, with variable results depending on the extent of the defect. Do w n s y n d ro m e (Tr is o m y 2 1) Down syndrom e is the m ost com m on genetic anom aly. 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. Most Down syndrom e children have a lower than average cognitive ability, often ranging from m ild to m oderate im pairm ent; a sm all num ber have severe to profound m ental disability. Very com m only they are seen as red blem ishes at the inner ends of the upper eyelids, som etim es on the nose and upper lip. The parents need to be reassured that these are norm al variants, are not due to traum a and that they will regress over the next few m onths without treatm ent. Strawberry m arks are generally not present at birth, appearing as tiny red dots in. If a drug is required, the doctor should read the product inform ation docum ent before prescribing it. In som e countries, lists of drugs that should be avoided during pregnancy are obtainable from the health authorities. Most com m unities have active Down syndrom e support groups and specialist health professional program m es. Unless required for cultural or religious reasons it should be delayed until the infant is 6 m onths old and should be perform ed under a local or a general anaesthetic. Ris k o f re cu r re n ce o f co n g e n it a l a b n o r m a lit ie s A question of great concern to the parents of a congenitally affected baby is: `What is the risk of our next baby being affected It is not necessarily applicable to all com m unities because o di erent genetic growth potentials; or instance the birthweights in a population o som e Pacif c Island groups would show higher growth centiles and som e Indian populations would show lower centiles. Causes and prevention o prem aturity are discussed in Chapter 19, with a sum m ary o causes given in Table 19. The intra-uterine growth o the etus depends on its inherited growth potential and the e ectiveness o the support to its growth provided by the uteroplacental environm ent. I possible the paediatrician should see the parents prior to the delivery to discuss the likely course o events and possible outcom es. In ants suspected o in ection and all those with respiratory distress that is not quickly and clearly settling should have investigations or in ection per orm ed and antibiotics started im m ediately. I the baby does not have the ability sa ely to suck and swallow a eed, then tube eeding or intravenous nutrition m ay be required. Low-birthweight in ants contribute 70% o early neonatal deaths; the sm aller and less m ature the in ant, the less its chance o survival (Table 27. I delivery is required be ore the 233 Fundam entals o Obstetrics and Gynaecology T able 27. The m orbidity o the surviving in ants has decreased in recent years; the highest m orbidity is am ong in ants whose gestational age is less than 27 weeks and whose birthweight is 750 g or less. An Australian study o outcom e at 2 years o age o 168 surviving in ants (a survival rate o 73%) who were born with birthweights less than 1000 g showed that 51% had no disability, 23% a m ild disability, 13% a m oderate disability and 14% a severe disability; 11% had cerebral palsy, 2% were blind and 2% were dea. For those born 20 years earlier the survival rate was 25%; disability rates were m ild 33%, m oderate 13% and severe 15%; cerebral palsy 14%, blindness 7% and dea ness 5%. This indicates that the wom an bled for 5 days and that m enstruation occurred at an interval of 28 days. Disorders of m enstruation occur m ost com m only at each extrem e of the reproductive years, that is, under the age of 19 and over the age of 39.

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The fetus is protected by the placenta in m ost cases hiv transmission statistics united states purchase medex online pills, although large num bers of im m obilized parasites m ay be found in the placenta hiv infection japan buy cheap medex 1mg line, particularly if the infection is by Plasmodium falciparum hiv infection likelihood purchase medex 5mg mastercard. Occasionally antiviral movie buy medex 1mg free shipping, in nonim m une patients, congenital transm ission of m alaria occurs. Pregnant wom en travelling to an area where m alaria is endem ic should take prophylactic antim alarial drugs. Prim ary infection can result in serious com plications for both m other and baby, because during pregnancy the m aternal im m une system is less ef cient. If the m aternal infection becom es apparent 7 days before or 7 days 150 Chapter 1 7 Infections during pregnancy evening, apply insect repellant frequently to exposed skin and sleep under insecticide-treated bed nets. Any pregnant wom an developing a high fever in a m alarial area should be suspected of having the infection, and if this is con rm ed by nding parasites in a thick blood lm, treatm ent is dependent on the local drug susceptibility of the m alarial parasites. If the risk of chloroquine resistance is low, chloroquine and proguanil should be given. If the risk of chloroquine resistance is high, after the rst trim ester m e oquine is the prophylactic drug of choice. In m ost cases this has no clinical signif cance, but occasionally m ay be ound in wom en who have antepartum or intrapartum haem orrhage. In other cases the placenta has an accessory lobe separated by m em branes rom the m ain placenta (placenta succenturiata). In a ew cases the trophoblastic invasion is not regulated by m aternal im m une de ences and the myom etrium is invaded, causing placenta accreta, increta or percreta. In m ost cases they are sm all and o no clinical signif cance, but larger haem angiom ata m ay be associated with polyhydram nios, antepartum haem orrhage or preterm labour. The um bilical cord m ay enter the placenta at its m idpoint, m ay join it at an edge (m arginal insertion o the cord) or the um bilical vessels m ay run som e distance along the m em branes (velam entous insertion o the cord). Should the vessels run across the cervix they m ay be com pressed by the etal head during labour, or bleed causing etal anaem ia (Chapter 13). In som e cases the placenta is sm aller than the chorionic plate and the trophoblast invades the decidua laterally m ore deeply, giving a ridged appearance on the placental sur ace (placenta circum val- Hy d a t id if o r m m o le the tum our m ay have com pletely or partially replaced the placenta. In the com plete orm, hydropic swelling and vesicle orm ation is associated with trophoblastic proli eration and a paucity or absence o blood vessels within the villi. In the partial orm a etus is present but areas o the placenta show the changes described or the com plete m ole. In over 90% o com plete m oles only paternal genes are ound, and in 10% the m ole is heterozygous. In contrast, partial m oles usually have a triploid, rarely tetraploid, chrom osom al constitution, with two sets o paternal haploid genes and one set o m aternal haploid genes, and there is usually evidence o a etus or etal red blood cells. The developm ent o gestational trophoblastic tum ours is thought to be due to a de ective m aternal im m une response to the invasion by the trophoblast. The prim itive vasculature within each villus does not orm properly, with the result that the em bryo starves, dies and is absorbed, whereas the trophoblast continues to thrive and, in certain circum stances, invades the m aternal tissues. Dia g n o s is o f b e n ig n g e s t a t io n a l t ro p h o b la s t ic d is e a s e the f rst sign is bleeding per vaginam, which tends to persist. The bleeding m ay be ollowed airly soon by uterine contractions and the expulsion o grape-like m aterial. Although rare the wom an m ay show signs o hyperthyroidism, preeclam psia or abdom inal distension rom large theca lutein ovarian cysts. In the invasive m ole the trophoblast-covered villi penetrate the myom etrial f bres and m ay extend to other organs, the appearance o the villi rem aining that o the benign tum our. T atme nt re I the patient is adm itted expelling the tum our, no im m ediate treatm ent is needed unless the expulsion slows down, at which tim e a digital evacuation o the uterus is carried out. Blood is obtained or possible trans usion, as the expulsion is o ten accom panied by m arked blood loss. I the diagnosis is reached be ore the expulsion o any vesicles, the uterus m ay be evacuated using a suction curette. The adm inistration o prostaglandins or oxytocics to induce contractions should be avoided as these m ay lead to the intravascular dissem ination o trophoblast. The normal range is shown in pink; levels found in trophoblastic disease are shown in the blue area. Som e authorities give a single course o chem otherapy i they think that the wom an presents with increased risk actors. Wom en over the age o 40, or wom en who have com pleted their am ily, m ay pre er to have a hysterectomy, to avoid potential m alignancy. Many countries have a m olar register so com pliance with ollow-up can be m onitored. Fo llo w -up Follow-up is im portant as the disease persists in between 5 and 10% o cases, o ten developing a m alignant orm. Po ly h y d r a m n io s Polyhydram nios is caused by increased secretion o am niotic uid because o a large placenta, or by a etal m al orm ation that prevents the etus swallowing the uid or prevents the absorption o the uid through the etal intestinal villi. Exam ples o the orm er are m ultiple pregnancy and diabetes and, o the latter, anencephaly, spina bif da and atresia o the upper gastrointestinal tract. The uid m ay accum ulate rapidly (acute polyhydram nios), which causes considerable distress to the m other. Treatm ent consists o rem oving am niotic uid by am niocentesis, repeated i necessary. Laser ablation o the com m unicating vessels on the sur ace o the placenta can be e ective therapy when there is evidence o twin to twin trans usion. The slow accum ulation o am niotic uid is m ore com m only ound (chronic polyhydram nios). Sym ptom s sim ilar to those o acute polyhydram nios m ay be experienced by the expectant m other, and exam ination shows a distended uterus rom which a uid thrill can be obtained.

Separation of the placenta takes place through the spongy layer of the decidua basalis hiv yeast infection in mouth order medex 1 mg on line, as the result of uterine contractions being added to the retraction of the uterus that follows the birth of the child antiviral bell's palsy purchase medex 5mg free shipping. The retraction of the uterus reduces the size of the placental bed to one-quarter of its size in pregnancy hiv infection rates heterosexual vs homosexual purchase medex mastercard, with the result that the placenta buckles inwards hiv symptoms three months after infection 1 mg medex with visa, tearing the blood vessels of the intervillous space and causing a retroplacental haem orrhage, which further separates the placenta. The process starts as the baby is born and separation is usually com plete within 5 m inutes, but the placenta m ay be held in the uterus for longer because the m em branes take longer to strip from the underlying decidua. Following the separation of the placenta, the lattice arrangem ents of the myom etrial bres effectively strangle the blood vessels supplying the placental bed, reducing further blood loss and encouraging the form ation of brin plugs in their torn ends. The contracted uterus is pushed down towards the pelvis, so that it acts as a piston to expel the placenta and m em branes from the vagina. The expelled placenta is grasped and twisted around with continuing traction to m ake the m em branes into a twisted cord so that they are expelled intact. The delivery of the baby following the injection is conducted slowly over 60 seconds. The slowness is because the oxytocic effect takes about 2 m inutes to produce a strong uterine contraction. When it occurs, the hand is placed suprapubically and pushes the uterus upwards while the right hand grasps the um bilical cord and pulls the placenta out of the vagina in a controlled m anner. The m em branes are drawn out intact by twisting them into a rope and pulling them out with a sponge forceps or the hand. T raditio nal o r e xpe ctant manag e me nt the placenta and m em branes are allowed to separate without interference. After a 10-m inute delay another attem pt is m ade to pull the placenta out by controlled cord traction. The advantages of active m anagem ent are that the risk of postpartum haem orrhage (a loss of >500 m L of blood) is reduced by half, there is a lower requirem ent for blood transfusions and the third stage of labour is shortened. There is no difference in retained placenta or the need for m anual rem oval of the placenta. The disadvantages include increased nausea and vom iting and hypertension if ergom etrine, rather than oxytocin, is used. Injectable prostaglandins and oral m isoprostol have been shown to be less effective than oxytocin and ergom etrine for the routine m anagem ent of the third stage. In s p e ct io n o f the p la ce n t a a n d m e m b ra n e s the placenta and m em branes are held up by the um bilical cord and the fetal surface is exam ined, attention being paid to the blood vessels to see if any run to the edge of the m em branes, indicating a possible succenturiate lobe. The m aternal surface of the placenta is exam ined next, any clots being washed away, so that the cotyledons can be inspected. The m aternal surface is held in both hands and tted together to m ake sure that no cotyledon has been left in the uterus. If any cotyledon is m issing, or if m ost of the m em branes have been left in the uterus or vagina, a doctor should explore the vagina and the uterine cavity under sterile conditions after ensuring that the wom an has adequate anaesthesia. A retained placenta is one which has rem ained in the uterus for m ore than 1 hour. As a retained placenta m ay be associated with haem orrhage, action should be taken to rem ove it. In this relatively uncom m on condition (1 in 1500 births) the trophoblast has invaded the decidua and myom etrium to varying degrees (placenta accreta) or has penetrated to the serosal coat (placenta percreta). Manag e me nt If postpartum bleeding is m arked, attem pts should be m ade at once to nd if the placenta has separated as described earlier, and attem pts should be m ade to deliver. Should the placenta be retained for 1 hour with little bleeding the above procedures should be undertaken. A placenta accreta or percreta m ay resist attem pts at m anual rem oval and hysterectomy m ay be perform ed. If the perineum has been torn or an episiotomy m ade, the tear or incision is now repaired after inspecting the vagina for dam age. If a dif cult forceps delivery has been m ade the cervix should be inspected to exclude a lateral tear. The idea was that episiotomy would prevent the developm ent of such tears and would also prevent the later developm ent of vaginal prolapse, although the evidence for this is dubious. Routine episiotomy has m ajor disadvantages: the wom an continues to have perineal pain and discom fort for longer than one who has not had the procedure, and in addition sexual intercourse m ay be uncom fortable for up to 6 m onths afterwards. If the episiotomy has extended to produce a third- or fourth-degree tear, unless the anal sphincter is correctly sutured the wom an m ay develop anal or urinary incontinence. If the wom an agrees to the procedure, the perineum should be in ltrated with a local anaesthetic, unless the wom an has already had an epidural anaesthetic. The m idline incision has the advantage that no large blood vessels are encountered and it is easier to repair. If a large episiotomy is needed, for exam ple, when a dif cult m idforceps delivery is anticipated, a m ediolateral episiotomy is preferred. This repair is the least painful postoperatively, particularly when 2/0 polyglycolic suture m aterial is used.

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