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By: D. Bengerd, M.B. B.CH., M.B.B.Ch., Ph.D.

Associate Professor, Georgetown University School of Medicine

Thus if only one X chromosome is present it results in streak gonads like in Turners syndrome skin care in winter discount 10 mg roacutan amex. So if testosterone and dihy drotestosterone is present in intrauterine life in females acne oral medication buy generic roacutan line, it results in male looking geni talia in females acne used cash roacutan 10 mg on-line, i acne 4 weeks pregnant cheap roacutan 40mg line. Remants are present in All lateral part of broad ligament, except Paroophoron which is present in medial part. Development of Mullerian ducts/paramesonephric ducts in females the 5th-6th week of intrauterine life of the embryo mullerian ducts develop as an invagination of intermediate cell mass. They approach each other in the midline after crossing the Wolffian duct and fuse. Note: the bipotential gonad develops into an ovary about two weeks later than the testicular development. Wolffian duct is also called as mesonephric duct Mesonephric tubules Paradidymis Mullerian/paramesonephric Regresses-Remnant is ducts Appendix of testes Urogenital sinus Urinary bladder, urethra, prostate, prostatic utricle, and bulbourethral glands Chapter 5 Congenital Malformations Contd. Transverse Vaginal Septum If there is a disorder in fusion of downgrowing Mullerian duct and upgrowing derivative of urogenital sinus, results in transverse vaginal septum which causes imperforate vagina (or vaginal agenesis). Transverse vaginal septum mostly corresponds to the level of external os (as most of them are located in the upper part). Q Management case of septa in lower and middle part of vagina- surgical removal of septa vaginally followed by reanastomosis. Q Here the uterus is outwardly normal but contains a complete or incomplete septum whichreflectsafailureinthebreakdownof the walls between the 2 ducts. Q It does not represent a defect in the fusion of the ducts, rather here one of Mullerian ducts is completely absent and so there is only 1 fallopian tube. Uterus, cervix, and vagina though appear to be normal are only half of the fully developed organ. This is because in order to distinguish between the two, uterine fundus should be visible. Chapter 5 Congenital Malformations 73 In Bicornuate uterus the 2 halves of mullerian duct do not fuse and there is defect in fusion of fundus as well. Unification operation is indicated in otherwise unexplained cases of infertility or if it has lead to 3 abortions. Q Options Include bicornuate uterus: (and if needed for Didelphys uterus) Unification surgery (done either hysteroscopically or by abdominal routeStrassman metroplasty). Some have satisfactory intercourse, but in many, vaginal size is inadequate and they need a surgical procedure eventually. Uterus present tubes and ovaries absent Which of the following condition does not present with both mullerian and wolffian duct structures Long arm of X chromosome All of the following structures are homologous except: a. None of above All of the following take part in male genital tract development except: a. As seen, the uterine cavity is divided into 2 by a septa, hence it is a hypteroscopic view of septate uterus. Bifid clitoric Ref:- Ieffcoates 8/e, page 198 the genetal tubercle is formed from two mesodermal bands which grows round from the dorsal aspect of the foetus in the 3rd week. These also provide for the musculature of the abdominal wall, musculature of the anterior wall of the bladder and urethra and pubic symphysis. Failure of these bands to develop properly or to fuse result in a bifid clitoris, ectopic vesicle, divarication of the foreparts of the labia maiora, absence of hair bearing skin of the pubes and a split pelvis. Munrokers Operative Obstetrics 10th/ed p 192-193; Jeffcoate 7th/ed p 204; Williams Gynae 1st/ed p 418 Management: Bicornuate uterus requires surgical treatment only when it causes habitual abortions. Q "When a bicornuate or septate uterus has caused not less than 3 miscarriages and no pregnancy has resulted in a viable child, surgery may be indicated. Shaw 15th/ed p 95; Williams Gynae 1st/ed p 416 Vaginal atresia is associated with uterine atresia and syndrome is called as Mayer Rokitansky Kuster Hauser syndrome (for -Jeffcoate 7th/ed p 204 -William Gynae 1st/ed p 418 "Surgical reconstruction of the bicornuate uterus has been advocated in women with multiple spontaneous abortions and in whom no Surgery done is: Unification surgery (Strassman) where an incision is made over the uterus and the 2 horns are sutured -Leon Speroff 8th/ed p 147 Ref. Williams Gynae 1st/ed p 417; Leon speroff 8th/ed p 147 78 Self Assessment & Review: Gynecology 4. Part of female genital system Ovary Fallopian tubes Uterus Cervix Upper part of vagina Lower part of vagina Urogenital Sinus Originates from Genital ridge Ref.

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Echocardiography may be diagnostic acne 2007 cheap roacutan online american express, but lesions < 2 mm in diameter or those on the tricuspid valve may be missed skin care lotion order generic roacutan line. Organisms that cause indolent endocarditis are most often viridans-group streptococci or Staphylococcus or Enterococcus species acne zeno discount 30mg roacutan mastercard. Among intravenous drug abusers and those with catheter-related infections acne quizzes roacutan 5mg line, Staphylococcus aureus is the predominant organism. Tubectomy in a heart patient who has recently delivered is best done after: [New Pattern Question] a. Kalindi 25 years female admitted as a case of septic abortion with tricuspid valve endocarditis. Pedal edema In which of the following heart diseases maternal mortality is found to be highest Patients with organic heart disease in pregnancy most commonly die during: [New Pattern Question] a. The best method of curtailing the second stage of labour in heart disease is by: [New Pattern Question] a. Congenital heart disease is most likely in the newborn of mothers suffering from all except: [New Pattern Question] a. Congenital heart disease of the mother Chances of adverse outcome in a heart disease patient are increased in all of the following periods except: [New Pattern Question] a. None of the above All of the following rules are increased in infants of heart disease patient except: [New Pattern Question] a. Neural tube defect In severe mitral stenosis during pregnancy area of mitral valve is: [New Pattern Question] a. During pregnancy due to relaxation of the smooth muscles of the arteries by the progesterone, blood pressure decreases (Ref. Diastolic murmur, Dyspnea on exertion and Nervousness or syncope on exertion ks fre co. William 24/e, p 59 m eb oo ks f 222 Self Assessment & Review: Obstetrics ks re o. Q yy Thesyndromedevelopswhenincreasedpulmonarybloodflowduetolefttorightshuntproducesarightsidepressure more than left side and hence reversal of shunt occurs and subsequently cyanosis develops. In others, heart failure develops after 28 weeks, when pregnancy induced hypervolemia is maximal (32 weeks). In the majority, however heart failure develops peripartum when the physiological capability for rapid changes in cardiac out put may be overwhelmed in presence of structural cardiac disease. But it is not clear whether maximum chances are during labour or immediate postpartum. Among stenotic disease-(in alphabetical order)-Aortic stenosiswill have the worst> Mitral stenosis>Pulmonary stenosis. Congenital heart disease and Mitral valve prolapse have the best prognosis So now this question becomes very easy-Mitarl vave prolapse has the best prognosis, so it is ruled out; Regurgitant lesions have a better prognosis than stenotic lesions so mitral regurgitation is also ruled out. Now we are left with 2 options, aortic stenosis and pulmonary stenosis-as I said go alphabetically, aortic stenosis will have a worse prognosis than pulmonary. Williams, 22/e, p 483 Pain relief is important for heart disease patients as pain can cause tachycardia, which in turn can cause cardiac failure. Epidural and spinal techniques are the most effective means of providing pain relief for labor. Dutta Obs 7/e, p 225 this is another way of asking, cardiac failure occurs most common at what time as the M/C cause of death in pregnant females with heart disease is congestive heart failure. Dutta Obs 7/e, p 278 Management of heart disease patient in 2nd stage: No maternal pushing and the tendency to delay in the second stage of labor is to be curtailed by forceps or ventouse under pudendal and/or perineal block anesthesia. Ventouse is preferable to forceps as it can be applied without putting the patient in lithotomy position (raising the legs increases the cardiac load). Fernando Arias 4/e, p 271, 272 Period of pregnancy during which a heart disease patient has high chances of adverse outcome are: 1. Fernando Arias 4/e, p 272 Effect of maternal cardiac disease on fetus: fre fre fre fre. Problem of anticoagulation: During pregnancy, the main problem is of anticoagulation. Heparin is safe for the fetus as it does not cross the placenta, but is less effective than warfarin in preventing thromboembolic events. Two or more abnormal values on 100 gm oral glucose tolerance test during pregnancy. Important: Gestational diabetes does not lead to congenital malformations in fetus. No further testing required as values > 200 mg/dl confirm the diagnosis of diabetes co m eb oo yy Performed by orally administering 50 g of glucose irrespective of previous meal and measuring venous plasma glucose 1 hour later. Ideally it should be performed in all pregnant females but all those who have average/high risk for diabetes should definitely be screened. High HbA1c during the first trimester is associated with increased risk of gross congenital malformations and during second trimester is associated with macrosomia (HbA1c <8. The only oral hypoglycemic drug approved for use in pregnancy is Glyburide and metformin.

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Since skin care therapist buy discount roacutan 20mg, our patient acne mechanica order roacutan 20mg without prescription, Sucheta is just 29 years and nulliparous-Myomectomy should be done acne 10 dpo buy genuine roacutan online. Dutta Gynae 6th/ed p 265 "Calcareous degeneration usually involves the subserous fibroids with small peduncle or myomas of postmenopausal women acne tretinoin cream 005 generic 30 mg roacutan with mastercard. Q It checks the numberQ, locationQ, and sizeQ of fibroids and helps to reduce overlooking small fibroids during surgery (which might lead to persistence or recurrence of symptoms). Uterine Curettage: It can also help in diagnosis of submucous fibroid by feeling of a bump during curettage. Q Laparoscopy: is helpful if uterine size is less than 12 weeks, for detection of subserous fibroid and not submucous. It can also differentiate a pedunculated fibroid from an ovarian tumor not revealed by clinical examination and ultrasound. Williams Gynae 1st/ed p 205 the question here does not specify whether the fibroid is asymptomatic or symptomatic. If the assessment of the adnexa is hindered by uterine size or contour, some may choose to add annual sonographic surveillance. Unfortunately, their prominent side effects, which include acne and hirsutism, preclude their use as first-line agents. Shaw 15th/ed pp 356-7; Jeffcoate 7th/ed pp 492-3 Fibroids do not lead to amenorrhea, they lead to menorrhagia/metrorrhagia 20. Dutta Gynae 6th/ed p 284 Symptoms of cervical fibroid are predominantly due to pressure effect on surrounding structures. Anterior cervical fibroid irritates the trigone of bladder causing frequency of micturition or even retention due to pressure effects. In lateral cervical fibroid, vascular obstruction may lead to hermorrhoids and rarely, edema of legs. Posterior cervical fibroid predominantly presents with retention of urine and constipation. Indication of myomectomy: Myomectomy is specifically indicated in an infertile woman, in recurent abortions and patients with symptomatic fibroid but desirous of bearing child and wishing to retain the uterus. As far as pressure symptoms are concerned, it means fibroid is symptomatic and all symptomatic fibroids need surgical management which could either be myomectomy or hysterectomy. Dutta Gynae 6th/ed p 269 Thus, placenta previa is not a complication of fibroid Abruptio placenta is a complication. Dutta Gynae 6th/ed p 278 Three dimensional ultrasonography can locate fibroids accurately. The theory suggests embolization of menstrual fragments occurs through vascular or lymphatic channels. Moderate: Multifocal disease, both superficial and invasive and associated with adhesions in tube and/or ovaries. Management of Infertility In minimal/mild endometrioies the cause of infertility is ovarian, either oogenesis is defective on ovum pickup is defective. Hence, management is superovulation with clomiphene followed by intrauterine insemination. The phenomenon of ovulation bleeding or mucus tinged with blood at the time of ovulation is called as mittlebutt. Q this may be associated with ovulation pain, although each may occur independently. Pain is associated with rupture of ovarian follicle at the time of ovulation Characteristics appears in the mid-menstrual period. Right ovarian vein syndrome: Right ovarian vein crosses the ureter at right angle.

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Dhingra 6/e acne 9 days before period purchase generic roacutan pills, p 314 Phonoasthemia is weakness of voice due to fatigue of phonatory muscles i skin care equipment wholesale purchase roacutan online. Low vagal paralysis: Here the nerve to cricothyroid is intact and the fibers to the recurrent laryngeal nerve are damaged acne 2016 order discount roacutan line. This is more common than the high vagal paralysis and occurs twice as frequently on the left side than the right because of its longer course skin care pakistan buy roacutan 20 mg free shipping. Neuritis is a common cause of isolated recurrent nerve paralysis following upper respiratory infection caused by influenza A or B virus. Points to Remember Laws Related to Nerve Palsies emons law: States that in a gradually advancing organic S lesionofrecurrentlaryngealnerveoritsfibresintheperipheral trunk, 3 stages can be observed. In the absence of cricoarytenoid joint fixation, an immobile vocal fold lying in the paramedian position has a total Unilateral recurrent laryngeal nerve palsy, while an immobile vocal fold in the lateral (cadaveric) position has combined paralysis of superior and recurrent laryngeal nerves. Therefore all the nerves supplying to half of the larynx are involved causing combined paralysis. Sometimes other cranial nerves may be involved due to tumor involvement at the base of the skull commonly due to nasopharyngeal carcinoma. The former relieves stridor, preserves good voice but has the disadvantage of a tracheostomy hole in the neck. The latter relieves airway obstruction but at the expense of a good voice, however, there is no tracheostomy hole in the neck. Widening the respiratory airway without a permanent tracheostomy (endoscopic or through external cervical approach). This can be achieved by (i) arytenoidectomy with suture, wood man procedure, Dowine procedure, (ii) arytenoidopexy (fixing the arytenoid in lateral position), (iii) lateralization of vocal cord and (iv) laser cordectomy (removal of one cord). These operations have now been replaced by less invasive techniques such as: (i) Transverse cordotomy (kashima operation) (ii) Partial arytenoidectomy (iii) Reinnervation procedures. Aim to innervate paralyzed posterior cricoarytenoid muscle by implanting a nerve muscle pedicle of sternohyoid or omohyoid muscle with its nerve supply from ansa hypoglossi. Epiglottopexy to close the laryngeal inlet, to protect the lungs from repeated aspiration, may be done. There occurs unilateral paralysis of all laryngeal muscles except the inter arytenoid which receives innervation from both the sides. If neurological lesion is progressive and irreversable total laryngectomy to prevent aspiration and lung infection. Paramedian Intermediate (cadaver) Partial abduction Full abduction Distance from midline 1. Dhingra 6/e, p 299 Semons law and Wegner and Grossman hypothesis are both related to vocal cord palsy. Wagner Grossman hypothesis states that in U/L recurrent laryngeal nerve palsy, cricothyroid muscle which receives innervation from superior laryngeal nerve keeps the cord in paramedian position due to its adduction action. External laryngeal nerve y the external laryngeal nerve lies in relation to superior thyroid artery. In U/L abductor palsy, the affected vocal cord assumes a median or paramedian position. The other is normal so one third patients are asymptomatic others may have some voice change. Dhingra 6/e, p 300 In bilateral abductor paralysis (due to B/L recurrent laryngeal nerve palsy), both the cords assume a median position due to unopposed action of cricothyroid muscle. Dhingra 6/e, p 302 Type 4 thyroplasty is used to lengthen the vocal cord and elevate the pitch. It converts male character of voice to female and is used in gender transformation. Neurologic disorder of larynx by Andrew Bilitzer, p 152 Materials used for medialization of the vocal cord include-fat, fascia, gelatin powder, collagen and miconized acellular human dermis. A 10-year-old boy developed hoarseness of voice following an attack of diphtheria. A patient presented with stridor and dyspnea which he developed after an attack of upper respiratory tract infection. Dhingra, 6/e, p 298; Scotts Brown 7/e p 2139 All the muscles which play any role in movement of vocal cord are supplied by recurrent laryngeal nerve except the cricothyroid muscle which receives its innervation from the external laryngeal nerve-a branch of superior laryngeal nerve. Maqbool 11/e, p 310 y Vocal cord are fibro elastic bands y They are formed by reflection of the mucosa over vocal ligaments y They have stratified squamous epithelium with no submucous layer y Their blood supply is poor and are almost devoid of lymphatics. Dhingra; 6/e p 298 this question can be solved easily if you know the course of Left and Right recurrent laryngeal nerve. So, any mediastinal causes viz mediastinal lymphadenopathy and aortic aneurysm would parlyse Lt. Vertebral secondaries Ref Schwartz surgery 8/e, p 509; Dhingra, 6/e, p 299 Vocal cord paralysis is most commonly iatrogenic in origin following surgery to Thyroid, parathyroid, carotid or cardiothoracic structures.