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The diagnosis of preeclampsia would be advanced to eclampsia if the woman in Question 1 developed which of the following A Severe, unremitting headache B Platelet count of 50,000/ l C Grand mal seizures D Blood pressure 180/120 mm Hg E Visual scotomata 3. The canines, premolars, and first molars have their roots above the mylohyoid insertion, so infections from these teeth tend to affect the sublingual space. Counselling with a trained psychosexual counsellor is required, after exclusion of organic disease. Target treatment towards the causes identified during the evaluation for infertility. Differential Diagnosis Chronic sinusitis with inspissated secretions Fungal mycetoma Trauma and sinonasal blood Teaching Points Allergic fungal sinusitis is a chronic inflammatory condition characterized by a hypersensitivity reaction to colonization of the sinus by fungi, often Aspergillus. She has been followed by her primary and was on inhaled glucocorticoids which she stopped when she had a positive pregnancy test. Rates of fetal alcohol syndrome are on the rise as more women consume alcohol during pregnancy. Cutaneous lesions (nevi, hairy patch, dimples) overlie the spinal abnormality in most cases. Maternal respiratory function and gas exchange are affected by the associated biochemical and mechanical alterations that occur in a normal pregnancy. Constipation and difficult defecation can be caused by large posterior leiomyomas. A hemoglobin and hematocrit should be obtained in women with heavy or prolonged bleeding to evaluate for anemia. Although it is likely that this patient has anovulatory or oligovulatory bleeding and using oral contraceptives may be important for treatment, it is most important to first rule out pregnancy. The pain resulting from the first stage of labor is primarily due to dilation of the cervix with consequent distention and stretching. It is divided in to four subtypes based on histologic features: embryonal, botryoid, alveolar, and pleomorphic. Management Supportive therapy Further Reading Ezaki Y, Tsutsumi K, Morikawa M, Nagata I. Anomalies can affect most organ systems, in particular anencephaly and spina bifida in the central nervous system, ventricular septal defects and situs inversus in the cardiac system, and a characteristic embryopathy called sacral agenesis or caudal regression. A Immediate cesarean section B Induction of labor C Admission to hospital for observation D Outpatient observation 5. Local spread, especially to regional lymph nodes, is common at the time of presentation. You suspect a vaginal yeast infection and would like to prepare a slide for microscopy. Juvenile granulosa cell tumors that occur in premenarchal women induce abnormal bleeding and breast development. Postoperative pain is reduced by using local anaesthetic on the tubes and in the skin incisions. There is an absence of superficial epithelial cells and a predominance of parabasal cells. It should be reserved for pregnancies complicated by moderate or severe hypertension (diastolic blood pressure more than 100 to 110 mm Hg), where it reduces the incidence of cardiovascular and cerebrovascular events. Estrogen stimulates proliferation and maturation of the vaginal epithelium, providing a physical barrier to infection. An alteration in the character of established menstrual cycles is the most common manifestation of perimenopause occurring in up to 90% of women. Patients with familial retinoblastoma have a strong propensity to develop second primary tumors, both inside and outside of the radiation field (up to 50% at 20 years, and 90% at 30 years). Expectant management can be continued as long as the woman is willing and there are no signs of infection. Primary dysmenorrhea accounts for most cases and is attributed to increased prostaglandin production with menses in the presence of normal anatomy. After exposure to more than 25 rad, classic fetal effects, including growth retardation, structural malformations, and fetal resorption, may be detected.

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Her cyclic bleeding pattern suggests that she does not have an ovulation disorder and that the bleeding is most likely from a structural problem. Thick secretions will predispose the patient to sudden mucus plugs, which, as it was in our case, may occlude a large bronchial branch. Urodynamic testing, including a cystometrogram and voiding studies, may be useful for demonstrating the type of incontinence present. Bleeding insinuates between the fetal membranes and uterus which may extravasate or may remain concealed. Deep-seated hematomas do not benefit from evacuation via a traditional open craniotomy but some case series and one randomized study indicated that stereotactic surgery with needle aspiration could be useful in deep seated hematoma. Some treatments that have been targeted at this population have unsubstantiated efficacy and possible harm. All patients with a neurosurgical procedure for metastasis from a highly malignant tumor or recurrent brain malignancy will succumb in a short time period. Pallor or vital sign instability suggests either brisk bleeding or long-standing bleeding with associated anemia. How to communicate this to family members or even whether to discuss the actual procedure of cardiopulmonary resuscitation has remained an underdeveloped field of medicine, and training of this part of end-of-life care in residencies is generally not common place. On physical examination, you notice increased hair on her lower abdomen and upper back, but the rest of the examination and her vitals are normal. After 7 days, nymphs arise from the nits and progress to the adult stage in 2 to 3 weeks. Progressive fatty replacement of breast tissue with atrophy of active glandular units occurs, with regression of fibrocystic changes. A 33-year-old woman, gravida 7, para 3214, presents at 28 weeks with complaints of vaginal bleeding. Teaching Points Immediate imaging is central to the diagnosis and treatment of acute stroke. In the patient with pubertal delay, a bone age is helpful to distinguish constitutional delay from true delayed puberty. Pain treatment is essential not only before but also during and after radiotherapy. Symptoms associated with nerve sheath tumors are variable but most commonly are pain and radiculopathy. A History Certain conditions may predispose women to certain types of vulvovaginal infections. Unlike with ovulatory infertility, where unifollicular development is desired, development of three to five follicles is the goal. Smooth muscle tumors of uncertain malignant potential are rare, and controversy exists as to how to best characterize these tumors. Barrier contraception Barrier methods physically prevent the sperm from getting through the cervix. When severe, these episodes are associated with transient elevations of intracranial pressure beginning after the onset of the changes in vital signs. The incidence of minor maternal complication of operative vaginal delivery, such as cervical and vaginal lacerations is 1. They usually occur in the setting of bacterial endocarditis (in up to 10% of infective endocarditis cases). After delivery, insulin requirements for patients with underlying diabetes decrease because of the decrease in estrogen, progesterone, placental insulinase, and human somatomammotropin. Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome. The cause of death in patients with glioblastoma is multifactorial: clinical factors and autopsy findings in 117 cases of supratentorial glioblastoma in adults. Careful examination of the contralateral hemisphere is important, as malformations on the other side may preclude hemispherectomy. C Other symptoms Dizziness, fainting spells, and palpitations from hypotension resulting from intra-abdominal hemorrhage may occur.

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She denies sexual activity, reports no medical problems, and her only prescribed medication is a face wash for acne. Cognitive function and memory may decline with advancing age as estrogen levels decrease. It is important to recognize that these are associations and not causality; patients need reassurance in this regard. Once invasive testing is initiated, further assessment of antibody titers is not indicated. Poor prognostic indicators are advanced stage, poorly differentiated tumours, clear cell tumours and slow or poor response to chemotherapy. The use of doxycycline is contraindicated in pregnancy because, like tetracycline, it can stain developing teeth. Prolonged return of fertility (median time from discontinuation to return of fertility, 8. Urine culture and urethral culture for gonorrhea and chlamydia should be performed. If more pills have been missed then continue the packet as normal but condoms should be used for 7 days. Postoperatively, adjuvant radiation therapy, and/or systemic chemotherapy with a taxane and gemcitabine may be employed. Surgical options include McIndoe technique using skin graft placed in a surgically created space between the bladder and rectum, Vecchietti procedure, or the Davidoff procedure. A serum lactic acid level > 4 mmol/L indicates tissue hypoperfusion and calls for aggressive hemodynamic support. To avoid pregnancy, a couple must restrict sexual intercourse from the end of menses to 1 to 2 days after the temperature elevation. There are associated facial, orbital, and ear abnormalities in many syndromic craniosynostosis patients. Up to 80% of users may become amenorrheic at 1 year due to progestin effects on the uterine lining. Labour is a normal physio logical process and most women will deliver safely without any management. In addition, intercourse may introduce new organisms in to the vagina, thus influencing the microenvironment. Family Planning: Contraception and Complications 369 Study Questions for Chapter 32 Directions: Match the description below with the best method of contraception. Examination: Examination may reveal cachexia, an abdominal or pelvic mass and ascites. Differential Diagnosis Nerve sheath tumor Pituitary adenoma Chordoma/chondrosarcoma Metastasis Sarcoidosis or other granulomatous process Tolosa-Hunt syndrome Teaching Points Meningioma is the most common tumor of the cavernous sinus. This is subjective, as what constitutes heavy bleeding to one woman may be quite normal for another. Neurosyphilis (1) this form of syphilis may occur at any stage of infection with T. In this case, a negative test indicates that the individual did not inherit the familial risk and is a true negative. Similar to intracranial epidermoids, diffusion imaging helps distinguish spinal epidermoids from other "cystic"-appearing masses. Advanced tumors and lesions involving the lower vagina are treated more appropriately by radiation, which should include treatment of the pelvic nodes and parametrial tissues. Intramu ral fibroids not distorting the cavity also reduce fertility though the mechanism is unclear. A baseline blood pressure enables comparison if hypertension occurs in later pregnancy.

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Symptoms of urethritis and pyuria and a negative urine culture in sexually active women suggest a chlamydial infection. If pregnancy is not established, the corpus luteum regresses, progesterone support is withdrawn and menses ensues. If Gram-negative intracellular diplococci are present, gonorrhea is the presumed diagnosis. Physical examination, including a pelvic examination, at regular intervals until remission to ensure adequate involution of pelvic organs. A single night of sleep deprivation increases ghrelin levels and feelings of hunger in normal-weight healthy men. This allows selection, and therefore implantation, only of embryos that will not be affected by the disorder for which it is being tested. Partial separaDifferentiation between placental abruption and placenta praevia Abruption Shock: Pain: Inconsistent with external loss Common, often severe Constant with exacerbations May be absent Often dark Placenta praevia Consistent with external loss No. In addition to the radiation risk from radioactive iodine used in thyroid disease, the iodine can concentrate in the fetal thyroid after 10 weeks of gestation and lead to fetal thyroid dysfunction. The most common locations are the inferior fourth ventricle (60%) and the lateral ventricle (35%, usually in the frontal horn and abutting the septum pellucidum). Sertaconazole nitrate (Ertaczo) cream 2% [30, 60 g] is a newer imidazole agent that possesses both fungicidal and fungistatic properties to eradicate existing infections. Usually a bony or cartilaginous spur is present at the inferior aspect of the cleft. You are monitoring the progress of a woman (gravida 2, para 0) who has been in labor for the past 24 hours; her membranes have been ruptured for 17 hours. Because a premature infant was born and lived for 1 month, it is a human being and a legal entity that can maintain a lawsuit. The loss of chromosomes 1p and 19q may be seen in up to 70% of oligodendrogliomas and is associated with an improved response to chemotherapy and a better prognosis. This cream can be used for up to 16 weeks and produces a 72% to 84% clearance rate with a 5% to 19% recurrence rate. It is painful, except when due to epidural anaesthesia or failure of the afferent pathways. Drugs such as the phenothiazine derivatives, reserpine, and ganglia blockers can interfere with the levels of dopamine and norepinephrine; use of these agents can cause elevated prolactin levels which result in amenorrhea, usually associated with galactorrhea. The Management of Women of Reproductive Age Attending Non-genitourinary Medicine Settings Complaining of Vaginal Discharge, 2006. Antioxidant therapy has been employed by some but there is no proven specific treatment. Continuous administration of exogenous progestogens maintains a secretory endometrium. There appears to be a familial tendency (higher rate for women with affected sisters, mothers, and grandmothers). The presence of a "dural tail" may be helpful but is not specific for meningiomas. The antagonistic effect of progesterone on the endometrium combined with inadequate estrogen stimulation results in atrophy. These are attached to the cervix and suspend the uterus from the pelvic sidewall and sacrum, respectively. Severe oligospermia is present when an ejaculate contains less than 5 million sperm per milliliter. If this woman sues the physician for negligence, which of the following would be his best defense A Labor is not a disease, so it was not necessary to attend to this pregnant woman B Because the woman did not come for prenatal visits, she is not entitled to a physician C Because the woman gave birth to a healthy infant, no harm was done D the physician never accepted the woman as his patient E the patient was contributorily negligent in not calling the physician long in advance of active labor 3. Patients should also be evaluated for the presence of other elements of the metabolic syndrome and should be managed accordingly. It is usually associated with a longitudinal vaginal septum that can be minimal or extend to the introitus. The remaining hemiuterus will function well for pregnancy, though careful obstetrical care is needed.

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After you perform a routine prenatal examination, you change her blood pressure medication to methyldopa and ask her to use it throughout the entire pregnancy. After 2 doses he was markedly better, and after 6 doses he had returned to baseline. Synchronous pineal and suprasellar masses strongly suggest the presence of germinoma. These patients show signs of androgen stimulation at puberty and may have ambiguous genitalia. They are thought to be acquired lesions and may form as a result of trauma or old venous sinus thrombosis. Of the approximately 1 million sexual assaults that occur each year, two-thirds of incidents are not reported to the police, and two-thirds of these acts are committed by a perpetrator known to the victim. When pain and a pelvic mass are present, it is imperative to further characterize the mass. Recruitment of accessory muscles can be visible on inspection, but it is best noted by palpating the sternocleidomastoid muscles. The differential diagnosis is broad, but can be sorted out quickly by a focused evaluation. Thirty-eight percent of cesarean sections performed in the United States were repeat cesarean sections in 2004. Other heterotopias include nodular subependymal (most common) and nodular subcortical. Cervical motion tenderness: lateral motion of the cervix on examination causes pain by putting tension on the adnexa 2. Also, optimal glycemic control with a hemoglobin A1C less than 6 will reduce fetal malformations. Complications of sling procedures may include infection and ulceration (especially with the use of synthetic grafts) and urinary retention. This value corresponds to the maximum amount that a woman on a normal diet can lose per cycle without becoming iron deficient. It is secreted in to the portal circulation, which carries it to the anterior lobe of the pituitary gland. Detection of adequate sperm production: semen analysis A normal semen analysis result virtually excludes a male cause for infertility. She is concerned with the risks that rubella infection can have on the developing fetus and desires vaccination. At that very moment the family is told the patient has died and is escorted out the operating room. The constellation of symptoms is due to an enzymatic defect which disrupts the normal pathway converting cholesterol to sex steroids and mineralocorticoids. Particular care is essential in addressing gynecologic concerns in this age group because both physical and emotional trauma may be inadvertently inflicted. Overtightening, incorrect apposition at perineal repair or extensive scar tissue commonly present with superficial dyspareunia. A 23-year-old woman, gravida 1, para 0, spontaneous abortion 1, has undergone colposcopy for evaluation of a high-grade lesion found on Pap smear. When the infarct results from occlusion of a segmental artery, the ipsilateral half of the vertebral body may also infarct, which can be a clue to the diagnosis. Bilirubin enters the amniotic fluid from fetal secretions, and the level of bilirubin in amniotic fluid correlates with fetal hemolysis. The technique is expensive and presents ethical dilemmas, but has been used in prenatal diagnosis of sex-linked disorders, trisomies, and both autosomal dominant and recessive conditions. There has been a recent increase in the number of infections caused by non-albicans species. Pulmonary embolism is always a possibility and must be ruled out because she is pregnant and has tachypnea, but it is lower down in the differential diagnosis. It provides an environment in which capacitation of spermatozoa, fertilization, and early development of the embryo take place.

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Because of the location of the uterine vessels, lateral perforations may be associated with hemorrhage. Her obstetrical history which had been complicated by infection suggests the possibility of pelvic adhesive disease which may cause chronic pelvic pain but unlikely to cause dysmenorrheal or menorrhagia. The woman is asked about her physical and mental state and given the opportunity to ask questions. Studies have shown a reduction in postoperative infections in women who received preoperative treatment. The current preparations contain low doses of estrogen (usually 20 to 35 g per pill). With either instrument, if moderate traction does not produce immediate and progressive descent, Caesarean section is indicated. Corneal reflexes cannot not be obtained, and oculocephalic reflexes cannot not be tested due to uncertainty of associated spine injury. What a reasonable patient would consider significant under similar circumstances E Exceptions to informed consent include the following: 1. The major nerves supplying the vulva include those derived from the pudendal, ilioinguinal, genitofemoral, and posterior femoral cutaneous nerves. Preimplantation diagnosis requires the use of in vitro fertilization techniques such that one cell from the early embryo or a polar body is extracted and assessment of (usually) a single gene disorder is then performed. The United States Preventative Services Task Force recently issued new guidelines suggesting targeted screening on the basis of the risk factors for women aged 40 to 49, and universal screening every 2 years beginning at age 50. Ethambutol: added for resistant strains (1) Safe in pregnancy (2) Side effect with higher doses: optic neuritis in the mother c. Use mupirocin (Bactroban) 2% cream for superficial bacterial infections (impetigo). No clinical trials have confirmed that hot flashes are precipitated by caffeine, alcohol, or stress. Commencing screening at 25 reduces the number of unnecessary recalls and colposcopies. There have been no reported cases of congenital rubella from inadvertent administration of the vaccine to pregnant women. Parity is not a risk factor in this patient because she has not had any vaginal deliveries and all of her cesarean sections were performed prior to initiation of labor. Yet, if surgery is being considered, one should not wait until the patient markedly worsens. In cases of a normal gynecologic examination, ultrasound can often identify intrauterine polyps or submucosal fibroids that lead to heavy bleeding. Toxoplasmosis leads to increased risk of congenital anomalies in the fetus if infection occurs early in pregnancy. Treatment is continued for another 10 days, with the daily dose of estrogen combined with 10 mg medroxyprogesterone. In the past, bacterial vaginitis was known as nonspecific vaginitis and Gardnerella vaginitis. Additionally, the earlier tight glycemic control is established, the lower the microvascular risk. Thesecondstage: Instrumental delivery, although rarely needed, requires similar caution. Treatment methods rely on removal or destruction of lesions defined on colposcopy as well as the cervical transformation zone. Although serious complications are rare, these are greater than with a normal vaginal delivery. A fetal ultrasound would be appropriate given the disparity between the gestational age and the fundal height.

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Dihydrotestosterone is required in utero for normal development of male external genitalia. Squamocolumnar junction exposed to vagina (a) Normal mature squamous cells Basal layer of immature squamous cells Basement membrane Cervical stroma (b) (c) (d). We have seen patients in whom small volumes of intravenous hypotonic fluids were detrimental while large volumes of free water given by nasogastric tube were not. Screening for chlamydia is recommended for all pregnant women as well as sexually active women 25 and under and older women with risk factors such as multiple sexual partners. A pelvic ultrasound will not be helpful in this situation as it will likely be normal after her recent surgical management. Lymph drains to the obturator and internal and external iliac nodes, and thence to the common iliac and para-aortic nodes. Thus, while intrauterine progestogens are very effective and recommended as a first line by the 14 Chapter 2 Excessive bleeding Exclude anaemia Exclude local causes and malignancy Exclude systemic cause Symptom relief also useful for dysmenorrhoea. B Hypogonadotropic amenorrhea Treatment is directed at the underlying cause of the hypogonadism and appropriate hormone replacement. Hypoglycemia requires immediate correction, while hyponatremia should be corrected more slowly. A Spontaneous abortion is expulsion of the products of conception without medical or mechanical intervention. This patient has advanced ovarian cancer and has had major abdominal surgery, and is now presenting with the classic sequelae of a partial or complete small bowel obstruction, including nausea, vomiting, absence of flatus or bowel movements, dehydration, tachycardia and hypotension. In the third trimester, leiomyomas may be a factor in malpresentation, mechanical obstruction, or uterine dystocia. The incubation period for the disease averages 8 days, with a range of 24 hours to several months. Asymptomatic bacteriuria predisposes the pregnant woman to the development of acute systemic pyelonephritis, which has serious complications for the mother and fetus and has been associated with premature labor and delivery. Atrophic changes in the vulvovaginal tissues result from estrogen withdrawal; the normal protective thickness of the vaginal epithelium depends on estrogen stimulation. The hypotension is treated with an intravenous fluid bolus of an isotonic solution that does not contain glucose. The chromosomes, gonads, and internal genitalia are female, but the external genitalia are virilized to varying degrees. Among the oral contraceptives, the progestin-only method is more effective in preventing pregnancy than the combination-pill, or Yuzpe, method (85% effective vs. Most women with regular cycles are ovulatory, and menorrhagia may result from subtle abnormalities of endometrial haemostasis or uterine prostaglandin levels. Well-controlled human studies are lacking, and animal studies are lacking as well or have shown a risk to the fetus. Uterus didelphys with obstructed hemivagina is associated with right renal agenesis much more frequently than left. Placenta Liquor Abdominal wall Lung tissue Spine A pulmonary vein Left ventricle Right ventricle. A tubo-ovarian abscess or pelvic abscess may first be appreciated on pelvic examination and can be further evaluated with an ultrasound. Additional diagnostic studies are based on individual presentation and physical examination. She is noted to have 5 cm left adenexal mass, which is tender to palpation and fixed to the pelvic sidewall. Treatment: Methadone has been used to treat pregnant opiate addicts for many years. Other patients fail to get any better, and some others develop hemorrhagic conversion or a large intracerebral hematoma. Ovulation induction regimens should be individualized to provide the minimum dose and duration of gonadotropin treatment.

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Classic clinical presentation includes focal neurologic deficits, most commonly limb weakness or ataxia. Increased tidal volume and nasal congestion have no effect on the ability to place an endotracheal tube. Untreated, secondary syphilis may develop weeks later, often with a rash, influenza-like symptoms and warty genital or perioral growths (condylomata lata). Many are diagnosed only at ultrasound: as this is now performed in most pregnancies, the diagnosis is seldom missed. Neonatal hypoglycemia also has a posterior predominance and shows restricted diffusion but occurs in a different clinical setting and does not enhance. Meningiomas arise from persistent arachnoid remnants and usually adhere to the dura. Women above 30 years old may have testing spaced to every 3 years if they have had three consecutive normal Pap tests, and no history of cervical dysplasia or compromised immune function. This preparation is available over the counter in the United States for women over the age of 18 years. Pancultures should be obtained before the first antibiotic dose if at all possible, but cannot delay the start of antibiotics. Lymphomas can cross the corpus callosum and often demonstrate restricted diffusion and relatively hypointense signal on T2-weighted images. The pubic arch is narrow, the sidewalls are convergent, the sacrum is anteriorly inclined, and the ischial spines are prominent, all of which are more obstructive to fetal passage. The fetus is delivered, on average, after 40 minutes (nulliparous) or 20 minutes (multiparous). After ventriculostomy was placed, the patient improved substantially, and eventually the ventriculostomy was weaned and removed. Associated with blue bulging introitus with valsalva due to obstruction 248 Chapter 21-Answers and Explanations Answers and Explanations 1. An extrusion is present if the width of disc material at its base measures less than its depth on axial images or if the material extends cranially or caudally beyond the disc on sagittal images. Small areas on the trunk or extremities can be treated with potent topical steroids, such as fluocinonide (Lidex) or desoximetasone (Topicort) 0. Biopsy, which shows superficial hyperkeratosis with basal atrophic and sclerotic changes in adults, is rarely indicated in the pediatric population. Donor cells are buffy-coat poor, washed irradiated, filtered, and resuspended in normal saline to a hematocrit of 70% to 75%. Intramuscular ergometrine will reduce bleeding by contracting the uterus, but is only used if the fetus is non-viable. A tympanic membrane is created from temporalis fascia and the ossicles are freed from the atresia plate, if adherent. For women with irregular cycles repeat progesterone tests may be required until menstruation starts. The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. They appear as either a cystic mass with enhancing mural nodule or as a nodular enhancing mass. Short acting (inhaled albuterol) is the primary treatment for acute exacerbations. One such significant effect is that most antiepileptic drugs increase metabolism of warfarin and therefore decrease its effect. Currently, chemotherapy, usually weekly intravenous cisplatin, is included in most situations in which radiation therapy is used. On clinical examination, cysts generally feel smooth, round or oval in shape, with distinct borders, and may be soft or firm in texture. The Supreme Court struck down the provision of the statute that required spousal notification.


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