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Longer duration of treatment with its anti-oestrogenic action causes menopausal symptoms and osteoporosis. A similar paraurethral tissue sling can be pulled up on the other side with a helical suture. Pregnancy rate following conservative surgery is 40%, 50% and 70% in severe, moderate and mild endometriosis, respectively. Low-dose heparin therapy is controversial; the decision usually depends on consideration of individual risks and benefits, and coagulation studies. Undergoes hepatic metabolism to an active compound (alpha-hydroxymidazolam) that is excreted renally. Sex cord tumours have a potential to secrete hormones which may manifest clinical symptoms like precocious puberty, menstrual disturbances and postmenopausal bleeding. Haematoma may follow dilatation of the cervix, if the cervix gets split and uterine vessels get torn. As the dread of malignancy stays once a woman suffers a molar pregnancy, she requires careful follow-up. The theca cell is responsible for the production of ovarian hormones, oestrogen and progesterone, sometimes extended to the production of androgens. Coitus takes place in a normal manner but the penis is withdrawn immediately before ejaculation. If the uterine contractions are weak or fail to occur, Syntocinon drip is started 6 h later. On the other hand, a mucus polyp is often bigger than 1 cm, sessile or pedunculated, mobile and permanent. This corpus luteum is larger and more cystic than the corpus luteum of menstruation and may attain the size of 2. There are often multiple small punctate strawberry spots on the vaginal vault and portio vaginalis of the cervix (strawberry vagina). The islands of lymphoid tissue in the basal layer of the endometrium scatter lymphocytes into the functional layer so that at this stage, there is a well-marked lymphocytic infiltration of the whole of the endometrium. Skeletal muscle is present in the upper third of the oesophagus, smooth muscle in the lower third, and both types in the middle third. Has also been instilled into the pleural cavity to treat recurrent pleural effusions. The redundant peritoneum of the pouch of Douglas is dissected, the peritoneal sac excised and the neck of the enterocele is ligatured. The ovaries may descend within the inguinal canal to lie in the labia majora, and if the clitoris is hypertrophied, it may at first glance resemble the penis, and the fused labioscrotal folds resemble a rudimentary scrotum. Features of the Mark 7 over the Mark 5 (all modern agents but desflurane): - more accurate and easily controllable output throughout different flow ranges. It, however, does reveal corpus luteal phase insufficiency and defective folliculogenesis. They are not useful in menopausal women with weak levator ani muscles or in the presence of vaginal scar. It is called a perineal anus, or it opens partly by way of an anal canal and partly as a fistula in the location of the perineal body, or it opens through the lower part of the posterior vaginal wall into the navicular fossa just within the fourchette. Bounded anteriorly by the anterior pillars of the fauces (with buccal cavity anteriorly), superiorly by the palate and inferiorly by the tip of the epiglottis. The forceps are then opened outside the trachea to dilate the soft tissues before being closed and passed into the trachea. Sensation of the continued presence of an amputated limb, occurring in up to 80% of patients. Endometriosis Endometriosis is a purplish swelling seen over the labia majora or episiotomy scar over the perineum. Specific attention must be paid to: smaller equipment, drug doses and fluid volumes; specialised equipment. Sometimes the patient may present with the complaint of continuous bleeding, so that the normal pattern can no longer be distinguished. A normal sperm is capable of penetrating the zona-free hamster egg, showing its fertilizing capacity. Although platelet dysfunction has been shown after perioperative use, bleeding problems are rare, although care is required if other drugs with anticoagulant actions are co-prescribed. Aquafol is a newly developed emulsification of propofol in water, which has similar properties to the parent agent but causes more pain on injection.

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Precocious puberty and increased libido with aggressive behaviour is reported in a few cases. Each fibre contains myofibrils, containing actin and myosin filaments and surrounded by sarcoplasmic reticulum and mitochondria. A new course of tablets should be commenced 7 days after the cessation of the previous course. Disadvantages of surgery are as follows: Surgery involves anaesthesia and laparoscopy. Advice regarding proper diet, adequate rest during menses, oral administration of haematinics, vitamins and protein supplements and to maintain a menstrual calendar noting duration and extent of blood loss. Obstructive apnoea may be precipitated in some cases of central alveolar hypoventilation. Regeneration is remarkably rapid and all elements of the endometrium including glands and new sprouting vessels are present at the end of 48 h. Types: amyotrophic lateral sclerosis: upper motor neurone lesions with spastic limb weakness. Indications for use in the acute setting: increased dyspnoea, tachypnoea and work of breathing. The signal potential was applied vertically across the beam, causing vertical deflection; a spatial reconstruction of the signal against time was then seen on the screen. Acute attacks may be precipitated by drugs, stress, infection, alcohol ingestion, menstruation, pregnancy and starvation, although not at every exposure. Acute pain is felt in the lower abdomen, but may spread upwards if generalized peritonitis ensues. Corpus Luteum of Pregnancy Following fertilization, the corpus luteum continues to grow and forms the corpus luteum of pregnancy. German physician; described and standardised lumbar puncture in 1891, originally as a treatment for hydrocephalus. Premature menopause, menorrhagia and dysmenorrhoea may occur in more than one member in a family. Their effectiveness may be reduced by indrawing of the soft tissues of the upper airway during inspiration. Oestrogen level of over 40 pg/mL exerts bone and cardiotrophic effect, but the level below 20 pg/mL may predispose to osteoporosis and ischaemic heart disease (Table 5. For inhalational anaesthetic agents, similar considerations as for uptake are involved, plus length of operation and degree of redistribution to fat. Knowledge of the timing of ovulation is needed in in vitro fertilization, in artificial insemination and in the control of fertility. It acts as a mechanical barrier and prevents entry of sperms into the cervical canal, absorbs semen and contains a spermicidal agent. Respiratory and autonomic failure occurs early and cardiac involvement, including myocarditis, is common. Many result from modification or substitution of the side chain on the nitrogen atom of parent analgesic drugs. Nestorone ring releases 150 mcg progestogen plus 15 mcg oestradiol daily-one ring remains effective for 1 year. Painful micturition is a prominent symptom in cystitis; the pain is experienced at the end of micturition when the inflamed surfaces of the bladder come into apposition. A new spermicidal cream, Tenofovir, prevents viral attachment to the vaginal mucosa and is nonirritant and is under development. Also reduces myocardial O2 consumption whilst increasing coronary blood flow, although coronary steal has been reported. Membrane potentials at given intracellular/extracellular concentrations of sodium, chloride and potassium ions together are calculated by the Goldman constant-field equation. The pouch of Douglas is opened, uterosacral ligaments identified and divided close to the cervix. Complications: hypoxaemia: may be related to rapid removal of airway gases, causing atelectasis, bronchospasm/ coughing or disconnection from the ventilator. T level although raised remains below 200 ng/dL, unlike that in ovarian tumour (see also Ch. Pyometra Pyometra is usually seen in elderly women and is one of the best recognized forms of chronic endometritis.

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Fertiloscope consists of two introducers, one for uterine cavity and the second to study the genital organs through the pouch of Douglas. Inhibits sodium/potassium exchange in the distal renal tubule, with retention of potassium and hydrogen ions. Lactating woman-the drug is secreted in the milk or lactation stopped temporarily. Myomatous polypi may be mistaken for mucous polypi but are firm and spherical, paler in colour than mucous polypi and of a larger diameter. Technique Hysteroscopy should be performed in the preovulatory phase when the endometrium is thin and bleeding is less likely to occur. During pregnancy, surgery is contraindicated, except in the case of a pedunculated fibroid if it undergoes torsion. Evidence for its involvement in pain transmission includes: distribution in the regions of pain pathways. The electrodes melt the collagen and elastin in the vessel wall to form a seal zone. Some genetic subtypes are associated with a milder clinical course (thalassaemia intermedia). The tubal serosa is stripped off the muscular layer in the midsegment of the tube, which is then excised. The tumour itself assumes a peculiar purple red colour and develops a fishy odour. Ultrasound can also identify adenomyosis as a diffuse growth with intramural cystic spaces, ovarian tumour, ectopic and adnexal mass. The ends of the tape are then brought forward retroperitoneally as described above, and attached to the external oblique aponeurosis. Tuberculous Ulcers Tuberculous ulcers are rare and if they do occur, concomitant lesions are commonly present on the cervix or the vulva. Powder burnt areas are the inactive and old lesions seen scattered over the pelvic peritoneum. Faecal incontinence may follow some years after the delivery, but many develop it within 6 months of delivery. A hole is made in the anterior leaf of the broad ligament and the fimbrial end is buried into this. Different ranges of particle size may be analysed by altering accelerator characteristics. The term is usually reserved for colloids, although hypertonic iv solutions act as short-term plasma expanders. Traditionally treated with rest, penicillin, aspirin and corticosteroids, but the effect of drugs on valve disease is controversial. Appendicectomy at the time of primary surgery prevents pseudomyxoma peritonei, as often mucocele of appendix is known to cause this complication. Oxytocin is produced by the paraventricular nucleus and vasopressin by the supraoptic nucleus of the hypothalamus. Additional intermittent progesterone therapy prevents breast and uterine malignancy. An acute pyosalpinx is surrounded by adhesions which fix it to the back of the broad ligament, the ovary, the sigmoid colon, adjacent coils of intestine and posterior surface of the uterus. Contraindications include previous abdominal surgery, drains, ileus and adhesions. If the skin is hard and tends to crack, a cream made of zinc oxide (40 parts) and olive oil (60 parts) or codliver oil helps to soften the skin. Experimentation with timing and duration is usually required to achieve maximal effects. Has been administered topically to the nasal mucosa and eye to cause vasoconstriction and mydriasis respectively, and as a vasoconstrictor agent for local anaesthesia. Also expressed as the product of the change in volume of a system and the pressure against which this change occurs. Removal of these tumours will restore the urinary tract to normal in 70% of cases. Most pain arises in pain receptors (nociceptors) widely distributed in the skin and musculoskeletal system.

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Clinical examination reveals a symmetrical enlargement of the uterus if the adenomyosis is diffuse and the uterus is tender. Irish-born anaesthetist, responsible for much of the innovation in, and development of, modern anaesthesia. Coitus should not be attempted until the perineotomy wound has healed soundly, usually in 3 or 4 weeks. Division into hypovolaemia, myocardial failure and peripheral vascular failure has been suggested as being more indicative of underlying mechanisms. Toxic alkaloid derived from tobacco, mimics certain actions of acetylcholine, and was used to investigate the physiology of the autonomic nervous system. In this method, the erectile penis is completely covered by a very thin rubber (condom) which is used only once. Clinical Approach the clinician is required to make an assessment of the cause of primary amenorrhoea on the basis of history, clinical examination and tests that are most likely to provide the answers to the underlying cause. Oftenmobile Pain Normally, benign ovarian tumours cause no abdominal pain and are comfortably placed in the abdominal cavity which is distensible. Colposcopy and pap smear of the cervix are also required to rule out concomitant pre-invasive cancer of the cervix. The maximum volume of gas that can be expired slowly after maximal inspiration; measured by a spirometer. May be: congenital: - deficiency of reducing enzymes (especially cytochrome b5 oxidase), that normally convert endogenously formed methaemoglobin to haemoglobin. Useful in 50% of women but of no help in 30% and, like opioids, there is little evidence that it reduces pain scores. Inclusion cyst is mainly seen at the lower end of the vagina on its posterior surface and is caused by tags of mucosa embedding inside the scar that later forms a cyst. The ovary should be observed for colour change from bluish black appearance to its normal appearance. Therefore, these procedures are mainly suitable for women who wish to preserve the uterus, avoid hysterectomy, but are not interested in pregnancy. Sevoflurane O2 consumption may be normal but O2 extraction and utilisation are reduced. Devices for bedside measurement of capillary blood haemoglobin concentration may be useful. After the menopause due to the deficiency of the ovarian hormones, the vaginal mucosa thins down and the exfoliated cells are predominantly parabasal and basal types. This should be treated with Dianette pill containing 35 mcg E2, 2 mg cyproterone acetate starting on the first day of cycle for 21 days each cycle. Hysterectomy and bilateral salpingooophorectomy may be resorted to if drug therapy fails in elderly women. A degree of atrioventricular block may be present, especially when associated with digoxin toxicity. The surgical removal or radiation should include all the regional glands for curative effect. Other indications for sterilization include the mentally retarded woman and the one suffering from serious psychiatric disorders like schizophrenia. Over the age of 40 years the fertility rate is reduced, and there is an increased risk of chromosomal abnormalities and other malformations in the fetus. The cervical involvement is mostly due to descending spread from the infected uterine cavity, or on occasions primarily from the husband suffering from genital tuberculosis through sexual intercourse. The dendritic zone is the site of integration of incoming impulses via dendrites, and of initiation of the action potential. Therefore, it is often difficult to differentiate between acute appendicitis and acute salpingitis. In young women, deep conization of the cervix can lead to midtrimester abortion, premature labour and cervical dystocia.

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The vagina is packed with betadine or acriflavine pack for 24 h, a Foley catheter left in the bladder, and urine continuously drained for 48 h. Today, endometrial biopsy is omitted as a routine investigation of infertility and ovulation best monitored by serial ultrasound scanning. Surprisingly, Mirena is not effective against endometrial hyperplasia caused by tamoxifen. Diagnosis the clinical features outlined above are easy to interpret, but certain reservations are of great importance. Complications include intravascular injection (including into the vertebral artery), recurrent laryngeal nerve and brachial plexus blocks, pneumothorax, subarachnoid and epidural injection, and haematoma formation. These factors determine how the effector site concentration of a drug varies over time. Maintenance of tissue oxygenation, organ function and metabolic and cardiovascular stability should be pursued as for critically ill patients, until and during organ removal. Normal pubic hair is distributed in an inverted triangle, with the base centred over the mons pubis. This test depends on the presence of oestrogen-primed endometrium in the uterine cavity. These patients seek medical consultation because of primary amenorrhoea or in case of presence of functional uterus (1:10 cases)-because of cyclic abdominal pain occurring as a result of occult menstruation. Gonococci and chlamydia travel up the genital tract along the mucous membrane to reach the fallopian tubes and cause salpingo-oophoritis. The cyst of the anterior vaginal wall is usually tense with well-defined margins and cannot be reduced on pressure. Anaesthetic management: - preoperatively: assessment of respiratory function is important. Eighteen hours after insemination, oocytes are observed for the presence of pronuclei (sign of fertilization) and cultured for a further 24 h. The bleeding may come as a trickle from the fallopian tube but more commonly it originates in the endometrium of the uterus. Rarely, phaeochromocytoma may present for the first time during incidental surgery, pregnancy or labour; morbidity and mortality are high in this context. Deficiency results in increased tendency to bleed and may result from: inadequate intake: rare in adults, common in the newborn. Advances in instrumentation and techniques now enable the endoscopist to accomplish several operative procedures hitherto performed only by open surgery, including cancer surgery. Behind the anus are the radial folds in the skin which are corrugated by the underlying contracted subcutaneous sphincter. Allow prospective and repeated observation and analysis of actions rather than retrospective assessment. All patients should be questioned for family history of anaesthetic problems, since many susceptible patients give a positive family history. These folds, the uterosacral folds, lie at the level of the internal os and pass backwards and upwards. Approach to diagnosis: All patients after the age of 14 years manifesting absence of breast development and oestrogen effects need to be investigated. The external layer lies immediately beneath the peritoneum and is longitudinal, the fibres passing from the cervix anteriorly over the fundus to reach the posterior surface of the cervix. Transverse vaginal septum can be very easily mistaken for congenital absence of the vagina. Pregnant Uterus A pregnant uterus should be thought of whenever a tumour is found arising from the pelvis. They may be precipitated by hypothermia, dehydration, infection, exertion and hypoxaemia. Biopsy reveals hyperkeratosis, thinning of the epidermal epithelium, flattening of the rete pegs and hyalinization of the tissue beneath the epidermis. Reflex sympathetic dystrophy, see Complex regional pain syndrome Reflux, see Gastro-oesophageal reflux Refractometer, see Interferometer Refractory period. When the genital tract as a cause of bleeding has been excluded, cystoscopy and proctoscopy may discover the cause of bleeding.

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In contrast, delayed trophoblastic development may end up as a cervical pregnancy. The same neurotransmitter may be excitatory at one synapse, and inhibitory at another. If the uterus is pulled forwards, two folds of peritoneum can be seen to pass backwards from the uterus to reach the parietal peritoneum lateral to the rectum. Failure of central control of breathing causes hypoxaemia, pulmonary hypertension and cardiac failure. The needle is then inserted through the lid margin at the junction of the outer one-third and inner two-thirds of the lower orbital rim, and directed downwards between the globe and orbital floor. They are adjuvants to surgery when a huge fibroid or multiple fibroids are encountered. Describe the anatomical changes and alterations in the hormonal profile that characterize menopause. Superior displacement of mitral valve leaflet tissue into the left atrium, above the mitral annular plane. In most of these women, the follicular phase of the cycle is accelerated resulting in shorter cycles. If that fails, D&C may be helpful mainly for diagnostic purpose, but a few women may benefit from it therapeutically. Failure in retroverted uterus is due to unequal distribution of heat over the endometrium. Dyspnoea and headache are common at > 20% methaemoglobin, although rate of formation is also important. Paraquat concentrations can be measured in the serum or (more easily) in the urine. General examination will reveal lymphadenopathy (tuberculosis), anaemia and swelling of feet. In secondary vaginismus, a minor degree of spasm is induced by painful local lesions such as small infected lacerations of the hymen, urethral caruncle, vulvitis, or a sequela of vaginal operations for the repair of prolapse when, as a result of the operation, the calibre of the introitus and the vagina is narrowed. Thought to be improved by administering up to a third of the fluid intake as 10% dextrose. Dysfunctional uterine bleeding, metropathia haemorrhagica, uterine polypi and endometrial hyperplasia. The perineum should be swabbed after micturition and defaecation with antiseptic solution and subsequently powdered. The internal sphincter represents the expanded distal portion of the circular smooth muscle of the rectum and is innervated by autonomic nerves. The nasopharynx is sealed by soft palate elevation and superior constrictor contraction, and the larynx by elevation and glottic closure. Has been used to indicate tissue perfusion; thought to be important in wound healing and susceptibility to infection. Reactive hyperplasia of the glandular epithelium may lead to papilla formation, sometimes there may be evidence of epithelial atypia. Common cause of cardiovascular and respiratory pathology in surgical and non-surgical patients. Little is known of the exact aetiology and particularly, of why only the myoma should be involved and not the myometrium. The need for attention to detail and proper record-keeping is just as important as in general anaesthetic practice. This therapy can still cause endometrial hyperplasia in 5% and atypical hyperplasia in 0. The layer is never well marked and is best represented by the circular muscle fibres around the internal os and the openings of the fallopian tubes. Urethral syndrome is noticed in postmenopausal women with oestrogen deficiency and is effectively treated with short-term oestrogen vaginal cream. Endometrial changes: these vary according to the different phases of the menstrual cycle.

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Secondary Malignancy Secondary malignant changes occur in 50% serous cystadenomas, 5% in mucinous cystadenomas, but only in 1. Epidemiology of recurrent vulvo vaginal Candidiasis: Identification and strain differentiation of Candida albicans. Other suggested indicators include the ability to open the mouth, protrude the tongue, cough, maintain sustained hand grip, and achieve adequate tidal volume, vital capacity (15 ml/kg) and inspiratory pressure (-20 cm H2O). Most presynaptic nerve endings bear terminal buttons (synaptic knobs), with up to several thousand from different cells contacting each postsynaptic neurone. During induction of anaesthesia, the patient is instructed to breathe through the nose. There is no evidence that the device predisposes to either cervical or endometrial cancer. If, however, chemotherapy is considered postoperatively, termination of early pregnancy is necessary because of teratogenicity of the drugs. It is pale looking, firm with infection and necrosis at the base if it protrudes through the cervix. Protocols may contribute to risk management by standardising care, although they are not universally viewed with approval. To be effective, the above require administration before the surgical stimulus; their effects last for several hours after single dosage. Normal phenomenon (especially in young people) characterised by alternating periods of slow and rapid heart rates. In lower doses, they are used to provide intraand postoperative analgesia, and to prevent the haemodynamic consequences of tracheal intubation and surgical stimulation. Initially, intravenous route is resorted to , but as the infection settles down, oral therapy may be started. P5-adult inverted triangular distribution of thick, coarse, dark curly hair spreading out towards the medial aspects of the thighs is evident. Initially thought to answer the need for rapid tracheal intubation without using suxamethonium. Availability of laparoscopic procedures has made it possible to diagnose with confidence small and early lesions, which are often asymptomatic, assess the extent and severity of the disease, and allow an accurate classification prior to initiating therapy. Methods of assessment include: blood lactate levels (> 2 mmol/l suggests insufficient oxygen delivery): a late marker. The plasma level of progesterone rises after ovulation and reaches a peak level of 15 ng/mL at mid-luteal phase. Those patients who show ureteric obstruction have a definitely poorer prognosis and it must be remembered that in 70% cases, patients of the carcinoma of the cervix die not of their primary disease but of bilateral renal obstruction. A few selective investigations like thyroid function profile, renal function tests and androgen estimation must be done when indicated. The possibility of aspiration pneumonitis precludes this technique in rapid sequence induction. Scoring system for the severity of multiple organ dysfunction in paediatric intensive care. Once decannulated, the stoma usually closes spontaneously within a few days, but surgical closure may be required. There is a considerable vascular and lymphatic intercommunication between the vesical and the vaginal vessels, a sinister relationship having a bearing on the surgery of malignant disease of this area. Originally developed for use in industry, now has a wide range of medical applications including: soft tissue imaging; assessment of blood flow; tumour ablation; and fragmentation of renal and biliary calculi (lithotripsy). Not 561 562 Thigh, lateral cutaneous nerve block indicated for monotherapy; usually used in combination with a biguanide or sulphonylurea.

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Warfarin crosses the placenta, risking placental or fetal haemorrhage if given in the third trimester. All of the above are excreted by the liver except chlorpropamide, which is excreted renally. A small hypoplastic uterus, genital tuberculosis and partial Asherman syndrome also cause hypomenorrhoea and need investigation and treatment. The abdominal distension and vomiting are then the first indications of gut injury and peritonitis. With a history of short period amenorrhoea, pain, vaginal bleeding and a tender mass with internal haemorrhage, it is impossible to be sure of the pelvic condition. Use of cadaveric or live donor tissues has increased with improved techniques and introduction of immunosuppressive drugs such as ciclosporin. Unless complications like torsion or rupture lead to an acute abdomen requiring surgical treatment, most cysts will resolve in due course of time. The teeth, tongue and palate are cleansed with toothpaste using a toothbrush or sponge-tipped swab. The gland is crenated, the lumen contains mucous secretion and the inner border of the cells is irregular. Condoms are made of latex which can be damaged by oil-based spermicidal agents; therefore, water-based spermicides should be used. Focal glomerulonephritis may lead to nephrotic syndrome and, rarely, renal failure. Joint dislocations, kyphoscoliosis, pes excavatum, inguinal and diaphragmatic herniae are common. The capsule consists of connective tissue which fixes the tumour to the myometrium. It has to be performed by recognized medical practitioners in a recognized place approved by the competent authority under the Act. Prodromal symptoms of burning or itching in the affected area often precede the attacks. The transudate of the vaginal epithelium and the desquamated cells of the cornified layer. Once-a-month intramuscular deep injection of combined oestrogen and progestogen are available in some countries. Foreign bodies like a retained pessary usually cause ulceration high up in the posterior vaginal fornix, and the presence of granulation tissue and unhealthy offensive vaginal discharge are other manifestations. Congestive dysmenorrhoea is often associated with pelvic inflammatory disease, fibroids and pelvic endometriosis. Relations: separated from the pericardium and superior vena cava by the right pulmonary artery. This natural protective mechanism is impaired during menstruation, after abortion and delivery, because the cervical canal becomes dilated, the protecting epithelium of the endometrium is shed, and raw surfaces are present in the cavity of the uterus. Preadmission clinics (involving assessment by an anaesthetist, surgeon or nurse) attempt to reduce the rate of delay and cancellation of surgical procedures caused by inadequate preparation of patients. Hyperprolactinaemia may be due to enlargement of the pituitary gland or due to a pituitary tumour. Semen washing removes the abnormal sperms, seminal plasma containing antibodies and other debris, as well as prostaglandins. Urogenital Diaphragm the urogenital diaphragm is also called the triangular ligament.

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