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Postpartum blues affect at least 50% of women, most commonly approximately 3 to 5 days postpartum. Follow-up for long-term treatment with clean intermittent catheterization for neurogenic bladder in children. Steroidogenesis is then channeled into other pathways, leading to increased production of androgens, which accounts for virilization. A common compounding effect is the failure of the compromised neonate to establish respiration at birth. Most importantly, caesarean section will be associated Planned vaginal birth versus elective caesarean section In 2000, the Term Breech Trial was published by Hannah et al. Vital signs and abdominal examination can be quickly established but often the most important step is the vaginal examination. Indirect inguinal hernias are more common in infants and children and are caused by a patent processus vaginalis. Vaginal discharge usually requires an examination under anaesthesia to make a diagnosis. T Complementary & Alternative Therapies There are no alternative therapies that will cure low T. As the progestogen is locally delivered with minimal systemic absorption, the side effect profile is different from progestogen implants and the indication for use includes those who are on enzyme-inducing medications or have contraindications to systemic hormonal therapy such as hypertension, smoking in 40-year-old plus women, or taking anticoagulants. Avoid raw or undercooked meats by washing food-preparation surfaces carefully, cooking meat to 66°C or higher or freezing meat for at least 24 hours at -12°C. Where even a remote chance of fetal demise would be unacceptable to the woman, delivery is the correct option. Stimulant laxatives such as senna (Senokot) are also safe in pregnancy and may be appropriate. In most cases, surgery is limited to unilateral salpingooophorectomy, peritoneal biopsies and sampling of pelvic and para-aortic lymph nodes. Administration of a bolus oxytocic with a fetus still in utero will produce profound fetal anoxia and possibly uterine rupture. Given that these medications work by increasing secretion from the anterior pituitary, they are only appropriate in situations of intact hypothalamo-pituitary function and therefore do not work in the setting of hypogonadotrophic hypogonadism. Congenital, inflammatory, neoplastic, and anatomic etiologies of urinary obstruction are all common. The first step will be to establish whether the patient is hypotensive: this immediately establishes whether the primary event is circulatory or respiratory/neurological. It may also present as vaginal bleeding after amniotomy or spontaneous rupture of membranes. In contrast, a pregnancy involving monozygotic twins will only have the maternal-age-related risk, but either both or neither twin will be affected. Assessment of sexual problems It is important to take a very full medical and sexual history when someone presents with a sexual problem (Box 52. A three-part study to investigate the incidence and potential etiologies of tadalafil-associated back pain or myalgia. If forceps rotation is to be attempted, a larger episiotomy is usually made and the Kielland forceps employed. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. Labour is painful and most commonly used techniques, apart from neuraxial block, provide little or, at best, modest analgesia for women with moderate or more intense pain. The vaginoscopic approach to hysteroscopy may be used as an alternative to the traditional technique (see ambulatory hysteroscopy). The contemporary clinical utility of the test has been questioned by many clinicians. Diagnosis is made by the presence of donovan bodies on tissue crush or biopsy specimens. The endoscopic appearance is of calcified white plaques adherent to a severely inflamed and ulcerated mucosa.

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A longitudinal tube along the urethral axis is formed on the inner surface of the prepuce, which is then transferred to the ventrum through a buttonhole incision at the base of the tube. Birth trauma, particularly if there is haematoma formation, results in a large load of haemoglobin to be broken down. The causes of haemorrhage in the newborn include deficiencies of vitamin K-dependent clotting factors. Bloodloss:afterbirth Blood loss following birth can occur due to a number of reasons: haemorrhagic conditions such as haemorrhagic disease of the newborn or thrombocytopenia birth trauma including large cephalohaematomas, rupture of the liver or spleen or adrenal haemorrhage haemorrhage from an inadequately clamped umbilical cord. This is almost always due to near-terminal fetal hypoxia but may also be seen with fetal tachyarrhythmias or fetal brain death. The groin has 2 distinct anatomic areas: ­ Inguinal canal ­ Femoral triangle r Chronic increased intra-abdominal pressure. Producing keratinizing, stratified, squamous cell­lined cysts supported by fibrous tissue, these cysts are considered special cases of teratoma, but are not truly considered a teratoma since only a single germinal layer and not the required 2 layers is represented. Assessment of clinical palpation of the axilla as a criterion for performing the sentinel node procedure in breast cancer. Down-regulate the hypothalamo­pituitary axis, leading to a hypo-oestrogenic state and improvement in symptoms of endometriosis. Extensive calcifications can be seen after some cases of cryotherapy of the prostate and with tuberculous involvement of the prostate. Many causes exist, but an acute cause in urology is a result of excessive nonelectrolyte irrigant absorption during endourologic procedures. They are impregnated with or covered in spermicide and provide a means of holding the spermicide in place rather than a true barrier. Tumours arising from the epithelial and stromal cell lines constitute the majority (70 to 80% and 10 to 15% respectively), with germ cell tumours and others constituting the remainder. The epidemiology, pathogenesis, and diagnosis of vulvovaginal candidosis: a mycological perspective. The inner surface of the prepuce is again transferred to the ventrum via a buttonhole at the base. If the circulation is particularly poor, there is a risk of placental insufficiency with intrauterine growth restriction. Specially designed light sources which emit high intensities of light at this wavelength should be used. Male dyspareunia is a complaint that appears to be effectively treated by correcting the sling exposure in the female partner. Usually latex, but an inflatable version allows for easy insertion and removal and an individualised fitting Third-degree uterovaginal prolapse with decreased perineal support Concave surface fits against the cervix or vaginal cuff. Clinical features of this syndrome include organomegaly, protruding macroglossia, exomphalos, ear abnormalities and hyperinsulinaemic hypoglycaemia. Both general and pelvic examination (including inspection or the vulva, vagina and cervix) will clarify aspects of the history and pinpoint pelvic pathology. Note the clearly separate gestational sacs, each surrounded by a thick echogenic ring. Prostatic infection with occasional abscess and scrotal infections with fistulas have been reported. Whether minor or serious, it is imperative that all care providers are attentive to maternal symptomatology, are able to distinguish the normal from the abnormal, take pains to alleviate symptoms where possible and provide ongoing maternal support where difficulties persist. Urgency of birth Animal experiments have examined the effects of complete anoxia in the term primate fetus. Use of psychopharmacological treatments for mental illness in pregnancy and lactation must weigh the risks and benefits for both mother and child. Septic arthritis is diagnosed by culture of infected synovial fluid, acquired via joint aspiration. Commonly used medications are anti-inflammatory agents (eg, corticosteroids, tetracyclines, dapsone) and immunosuppressants (eg, azathioprine, methotrexate, mycophenolate mofetil, cyclophosphamide). It is characterized by grouped excoriations, urticarial plaques, and papules with vesicles, and has been described on the external genitalia.

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Less common is bilateral hilar adenopathy and pulmonary infiltrate (25%) and pulmonary infiltrate alone (15%). Finasteride for treatment of refractory hemospermia: Prospective placebo-controlled study. Serum bicarbonate values are taken at hours 2 and 4 to ensure adequate acidification (<16 mmol/L). It is best to think of the differential diagnosis in terms of the likely organ involved and then secondarily what might cause pain at that location. The pathways which result in focal seizures spreading to become a generalised seizure have not yet fully developed. Sexual Perpetrator receives the masochism humiliation/suffering (practice can lead to death, especially during "hypoxyphilia" or sexual arousal during hypoxia). No head will be palpable abdominally and the vertex has at least reached the level of the ischial spines in the absence of caput and moulding. They can be confused with lymphangioma circumscriptum, a uncommon tumor of the lymphatic channels. Infections such as molluscum contagiosum, which is a pox virus and is very common. A double blind randomised placebo-controlled study of intramuscular pethidine for pain relief in labour. Oxytocin causes contraction of the myoepithelial cells in the mammary alveoli, forcing milk into the lactiferous ducts. An instrumental birth can only be contemplated if the cervix is fully dilated and both the presentation and station are favourable. Pathologic Findings r Sporadic tumors are solitary, well-circumscribed, and encapsulated. Further ischaemia leads to degeneration of the whole stratum functionalis, which is progressively shed as menses. Although debated, measured compartment pressure of 30 mm Hg is a generally accepted indication for lower extremity fasciotomy. Treatment comprises active resuscitation with the provision of ventilatory support, as well as cardiovascular support (inotropes, intravenous fluid resuscitation). Topical hydrocortisone is useful for treating inflammation as a short course of therapy. Effect of ґ treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. Incidence the incidence of serious systemic infection is dependent on the population with the above risk factors. Bilateral cleft lip and palate may be associated with a more generalised midline defect with abnormalities of the brain and pituitary gland. However, the test has a negative predictive value of 97% for delivery within 7 days and may be useful in minimising unnecessary interventions, such as the administration of steroids, admission to hospital or transfer to another hospital. Traditional assessment tools include the Madsen­Iversen Point System and the Boyarsky Guidelines. Because of the risk of cervical or endometrial cancer, it is necessary to warn all women that any bleeding except that occurring in a normal menstrual pattern must be reported to a doctor. Good communication between physician and patient is imperative in preventing this challenging complication. Severely growth-restricted newborns (< 3rd percentile) often exhibit some degree of catch-up growth in the first several years, but often remain small. In severe cases there have been deaths, largely from initially unrecognised hollow viscus injuries, or catastrophic vessel damage; 50% of these injuries will occur on entry. Complementary & Alternative Therapies Combination of chemotherapy, radiation therapy, and surgery is recommended for advanced female urethral cancer. Unlike for hepatitis B, there is no vaccine or immunoglobulin available to mitigate the risk of vertical transmission of hepatitis C. Adequate procedural analgesia is necessary and post-procedure analgesia is highly encouraged. Comparative effectiveness of cisplatin-based and carboplatinbased chemotherapy for treatment of advanced urothelial carcinoma.

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Thrombocytopenia usually results from an increased destruction of platelets, which may be due to factors in the mother, fetus or newborn. Not every gynaecological patient will be examined vaginally and in general, no patient who has not been sexually active should be examined vaginally. Dwell for 1­4 hr, 4 times a day for 5­7 days ­ Stabilizes membranes, decreasing edema; causes vasoconstriction and platelet aggregation ­ Low morbidity: No anesthesia required, no precipitate forms, so no clogging of catheters ­ Adverse effects: Cost, requires intensive nursing care, moderate bladder spasms r Phenol instillation: ­ 30 mL 100% phenol in 30 mL of glycine for 1 min, then ethanol and saline washes ­ Destroys urothelium, not muscularis; less bladder fibrosis than with formalin ­ Painful, requires anesthesia ­ Duration of response is often short r Low-dose cidofovir (3) ­ 5 mg/kg in 60 mL of 0. High-grade, poorly differentiated serous tumours tend to lack psammoma bodies and have a more solid appearance, with areas of haemorrhage and necrosis. Sexual intercourse should be avoided until both parties are asymptomatic and the therapy course has been completed. Referral to a family cancer clinic is recommended if: a woman indicates that her family members have breast and or ovarian cancer at a young age multiple family members have breast or ovarian cancer breast and ovarian cancer has occurred in an individual family member bilateral breast cancer has occurred in an individual family member a woman is of Jewish descent and has a personal or family history of breast or ovarian cancer. General guideline to reduce the risk of fistula development is the use of the smallest caliber, softest flexible ureteric stent for the shortest possible period. Gonorrhoea is associated with lower education and socioeconomic circumstances and is more usual in inner-urban areas. The cause is unknown, but there is a familial association with this and other atopic diseases (allergic rhinitis, asthma). The vagina is often inflamed looking with the features of atrophy (thin vaginal skin with loss of rugosity). In the context of fetal thrombocytopenia, it is not known whether delivery by caesarean section reduces the risk of haemorrhage during delivery. A change in the pH of vaginal fluid from acidic to neutral occurs that increases urinary infections. Common indications include fetal compromise and delay in the second stage of labour. Maternal platelet and circulating antibody levels do not reliably predict the severity of thrombocytopenia. Formulations are either monophasic or multiphasic where there are two or more formulations within the active tablets. Pathophysiology of autonomic dysreflexia: Long-term treatment with terazosin in adult and pediatric spinal cord injury patients manifesting recurrent dysreflexic episodes. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in children. The woman should be admitted to an area where both mother and fetus can be monitored closely. They are almost always benign, although malignant transformation has been reported in up to 1% of mature teratomas. Surgical myomectomy Myomectomy can be performed abdominally (open or laparoscopic) or vaginally (hysteroscopic). Maternal vascular disease Women with vascular diseases are also more likely to develop preeclampsia. Primary retroperitoneal mucinous cystadenoma: a case study and review of literature. A uterine sarcoma may occasionally be diagnosed on endometrial biopsy in the work-up of abnormal bleeding. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of the North American Menopause Society. The adrenals are a rare primary site of disease, with bilateral, clinical, adrenal involvement in 18% of non-Hodgkin lymphoma and 9% of Hodgkin lymphoma. If acute, one should rule out pregnancy and then determine if it cyclical or non-cyclical. Shoulder dystocia can occur as a complication of large for gestational age infants. Most commonly it is disproportion between bony skull of the fetus and the bony pelvis but, as indicated above, obstructed labour can be due to soft tissue obstruction or a fetal anomaly or malpresentation. This, of course, is particularly unfortunate as the longer gestation adds to the likelihood of dystocia in association with obesity and a large fetus. In this unusual case there were also two anuses separated by a tail, and the double heart was in the neck due to absence of the normal attachment of pericardium to diaphragm. Long-term problems include dysmenorrhea, dyspareunia, fibrosis, keloids, sebaceous cysts, vulvar abscesses, infertility, and difficulty with pelvic exams, coitus, and vaginal delivery. Acupuncture may provide some relief; however, the magnitude of effect is moderate and evidence is confined to a small number of studies.

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Malignant hypertension may follow unilateral radiation and resolve with nephrectomy. Anterior vaginal wall 488 Manchester repair In the early 1900s Fothergill and Donald from Manchester described a technique that became known as the Manchester-Fothergill procedure. There are specific problems with vaginal breech birth that do not apply to a cephalic presentation. As a guide, particularly heavy bleeding may be indicated by the presence of clots, the need to change a pad or tampon more often than every 3 hours or the need to change a pad overnight. It is thought to result embryologically from an incomplete breakdown of the wall between the ectoderm and the urethra being formed by the urethral folds. B the usual type of mid-forceps delivery: the lowest part of the presenting part (vertex) is past the level of the ischial spines and the maximum diameter of the head is through the pelvic inlet. Chapter 9 Screening, Diagnosis and Management of Genetic and Structural Abnormalities in the Fetus Although many women will wish to return home soon after delivery, postnatal bereavement support is essential, and early postnatal review is recommended to assess physical and emotional recovery. The normal adult level is <8 ng/mL; this can be elevated in 38% of cases of embryonal cell carcinoma, 64% of teratocarcinoma, and in yolk sac tumors. However, in many cases the cord is subsequently found to have been high above the pelvic brim and the reason for the asphyxia is unclear. These questions should cover both storage (daytime and nocturnal urinary frequency, urgency, urge urinary incontinence, stress urinary incontinence) and voiding (quality of stream, straining to void) symptoms. Patients with blood at the urethral meatus, perineal hematoma, or urinary retention after blunt force trauma should be suspected of having a urethral injury. Diagnosed by high levels of deoxycorticosterone and/or 11-deoxycortisol in serum or their tetrahydrometabolites in a 24-hr urine. The preprocedure regimen is similar to transrectal ultrasound-guided prostate biopsy. The classic presentation is that of vaginal bleeding associated with abdominal and/or back pain. In this stage, the woman is at considerable risk of selfinjury (tongue biting, striking herself against unyielding surroundings, or falling out of bed). Cone biopsy is performed only if microinvasion is suspected colposcopically or on target biopsy. In Australia, various states and territories offer neonatal resuscitation training. Presents most commonly in childhood with bilateral flank masses, which are large kidneys with many cysts. Surgery and radiation therapy Surgical resection of pituitary tumours is usually reserved for situations where symptomatic tumours fail to respond to medical treatment or patients suffer intolerable side effects from such treatment. Other conditions Atrophic vaginitis Inflammation of the vagina due to low oestrogen levels occurs commonly in peri- and postmenopausal women and to a lesser extent in lactating women. Typically presents in the 60s or 70s with lesions that appear as crusted, indurated, erythematous to whitish patches. Hypothalamic­pituitary causes Delay in the hypothalamic initiation of pubertal changes can occur due to familial patterns (siblings or parents may be similarly affected), low body weight (eating disorder), excess exercise or a general health issue. Bacteria are thought to play a role in the enterohepatic recirculation of bilirubin and its byproducts. These agents-in contrast to oral steroids such as prednisolone- cross the placenta and accelerate fetal lung maturity. Transverse or posterior position with inadequate progress in the second stage A number of options are available: 1. There is a risk of fetal haemorrhage from a scalp wound, particularly if there is unexpected fetal thrombocytopenia. Families in which this altered gene is found were determined to have a lower age at diagnosis, a higher grade of cancer, and more cases of advanced disease than normal. Mild urgency: I could postpone voiding as long as necessary without fear of wetting myself. These data correlated with better penile hygiene resulting from improvements in sanitary conditions. The most common drugs with side effects afflicting the penis are tetracycline, phenolphthalein, sulfonamides, barbiturates, salicylates, penicillins, foscarnet, and Coumadin. The most common causes of pruritus vulvae are the dermatoses and fungal infections of the vagina and vulva. G the biparietal diameter of the fetal head is enclosed within the widest diameter of the forceps and the tips overlie the fetal cheeks.

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The infant is not at risk of kernicterus in the uncomplicated case because the bilirubin concentrations are not high enough and hence phototherapy is not required. Immediately after surgical closure Once surgical closure is complete, a vaginal examination ensures that no pack remains and a rectal examination excludes stitches in the rectum or anal canal. An evidence-based approach to decrease early post-operative urinary retention following urogynecologic surgery. The fetal surface is examined to determine if there could be a missing section of the placenta. Potential complications with the prescrotal approach for the palpable undescended testis? Confounding conditions such as premature ovarian insufficiency, thyroid dysfunction or hyperprolactinaemia can also cause oligomenorrhoea, and should be excluded. The small size of particles (90% <40 m) allows them to be phagocytosed, which can result in distant migration and granuloma formation. Patients may present with hydrocolpos or mucocolpos that may obstruct the urinary tract. For the male partner, past history of note includes previous paternities, as well as a history of undescended testes, mumps or genital trauma. Characterization of immunoglobulins and cytokines in human cervical mucus: influence of exogenous and endogenous hormones. Congenital fistulas account for 20% and are often found under the mucosa, accounting for the bleeding presentation. After aspiration of the oocyte, the eggs are incubated and placed in culture media. Anaphylaxis is particularly severe on the uteroplacental circulation with the potential for long-term sequelae. The lower segment is exposed with the aid of a curved retractor and the loose peritoneum over it is cut with curved scissors. Multiple psychological and biological factors influence the information processing of sexual stimuli. Because congenital cardiac anomalies are found in 1/2 of the patients, all patients with this syndrome should have cardiac evaluation and close follow-up. A Pretreatment cervical tumour expanding the cervix and extending into the lower part of the corpus uteri. The release of additional loops can be achieved quite easily by unwinding the clamped ends around the neck. Irreversible arrest at the primary spermatocyte or spermatid level has a genetic origin due to chromosomal anomalies. Treatment of suspected or documented infection is with intravenous ampicillin 2 g 6-hourly. While normal findings improve positive feelings about the pregnancy and have been shown to promote earlier bonding, the finding of isolated or multiple serious abnormalities on prenatal ultrasound examination is inevitably stressful. Cardiac arrest in pregnancy may benefit from immediate caesarean section in order to facilitate maternal resuscitation. Other congenital disorders include undescended testes, testicular dysgenesis or anorchia. Depot medroxy progesterone acetate and levonorgestrel intrauterine systems (inserted under general anaesthetic in the non-sexually active teenager) are options that are occasionally required. A widely used regimen places 10 units per 1000 mL normal saline or Hartmann solution (10 units/L). Foscarnet can cause periurethral ulcerations and coumadin can cause a hemorrhagic necrosis of the penis. In fact, the anti-D does cross the placenta and bind to fetal red cells but the amount of anti-D is very small and the amount of haemolysis occurring clinically insignificant. Birth asphyxia Once the head has been delivered, there is increasing risk of fetal asphyxia as time elapses. Continuing or excessive bleeding is always abnormal and may lead to iron deficiency anaemia. Approximately 1 in 500 cases undergoing surgery with uterine fibroids have a histological diagnosis of leiomyosarcoma. A large proportion (nearly 90%) of right ven tricular outflow blood is hence directed to the systemic circulation via the ductus arteriosus.

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By several weeks, it is thought that a newborn can visually discriminate between their mother and a stranger. If an umbilical hernia is present, the bowel contents protrude through this defect, especially during crying or straining. Pre- and post-prostaglandin fetal surveillance A reactive antenatal cardiotocograph should immediately precede the administration of prostaglandins, both the first dose and any subsequent doses. Lifestyle factors and duration of androgen deprivation affect bone mineral density of patients with prostate cancer during 1st year of therapy. If a coincident acidosis is suspected in the mother, a sample of her blood should also be taken for analysis. The patient desirous of fertility will want to ovulate but the patient who does not wish to be pregnant can have any hormonal deficiency treated by replacement. On one side, myomectomy will reduce the likelihood of the obstetric complications mentioned previously. The contraindications to breastfeeding are minimal, and need to be balanced with other important considerations (see Chapter 67). Although preeclampsia is more common in nulliparas, it is important to remember that the disease can be severe and of sudden onset in multiparas. If these are normal and there is no other explanation, imaging of the pituitary may be required. Complications are as per ablative treatment, with additional concern being raised about the risk of obstetric complications with premature rupture of membrane or premature labour. If it is not, then unilateral or bilateral undescended testes should be suspected. Surgical history In particular, this should include history of abdominal or pelvic procedures. This has occurred in approximately 20% of pregnancies prior to birth, most often during labour. The skin lesions begin as patches, plaques, or papules, then coalesce to form a woody skin appearance. With drug-related interstitial nephritis, allergic-type reactions may be present, such as rash, fever, and eosinophilia. Management consists of dilation, endoscopic incision (laser, cold cut, electrosurgical) or resection, and, in severe cases, open repair utilizing a Y­V plasty. If the lower placental edge impinges on the lower uterine segment but is more than 2 cm away from the internal cervical os, vaginal birth may still be possible. Trichomoniasis is a cause of vaginitis and produces a malodorous, greenish and frothy discharge. The appearance begins as a flaccid vesicle or bulla with associated itching, irritation, and a possible odor. Low birth weight newborns comprise approximately 6% of all births but can account for up to 80% of neonatal deaths. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: A randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lichen sclerosus is a rare (1 in 800 children) but very important cause of chronic pruritus as it can cause significant and permanent scarring if left untreated. Management is identical to any adrenal mass: Assessment of functional status of the tumor with surgery if the patient is symptomatic or lesion is >5 cm (risk of malignancy and possibly bleeding). Transient obstruction during early development may be responsible for the fusiform type. In the great majority of women with urinary infection, a coliform or other gram-negative organism is cultured. The primary role of tocolysis is to allow for administration of steroids for fetal lung maturity and to allow transfer of the mother to a hospital with appropriate neonatal facilities. Stroke may occur in hypertensive disorders and is most often occipital in severe preeclampsia. An active, carrier-mediated transport mechanism for choline allows for uptake into tumor cells where it is phosphorylated by choline kinase, an enzyme that is often upregulated in cancer.

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Reduced ventricular filling may be due to mitral/ tricuspid stenosis or reduced venous return. It is estimated that only five vaccination doses are necessary to prevent one case of serious maternal or infant respiratory illness. It should not be regarded as a primary psychological disorder but a condition that can lead to secondary psychosexual problems. Approximately 50% of Australian women are seronegative and 1% will seroconvert (primary infection) during pregnancy. When mastitis has occurred, the breast should be emptied adequately, usually by allowing the baby to suckle, but by manual expression as well if necessary. Other women and their infants experience hurdles to breastfeeding, which can usually be overcome. Oligomenorrhoea and amenorrhoea can have important implications for fertility as well as leading to adverse consequences such as osteoporosis in settings of low oestrogen states or endometrial hyperplasia in cases of chronic anovulation (leading to a lack of progesterone, which is protective against endometrial hyperplasia). Obstructed labour (Ch 34) True obstructed labour is now relatively uncommon as most labours progress slowly before developing signs of obstruction and the caesarean section is performed for slow progress before all signs of obstruction have developed. Focal fat stranding can signal a focus of acute disease and should prompt inspection of adjacent structures. However, bacterial vaginosis and the microflora of the lower genital tract are also implicated. Most women will thus only be diagnosed following seroconversion after a known contact. The cause in 95% of cases of trisomy 21 is non-disjunction during oogenesis in the mother. Patients typically present with a hydrocele, but the initial physical exam rarely suggests malignancy. The relationship between renal tumor size and metastases in patients with von Hippel-Lindau disease. Surgical removal is best performed early in the second trimester and would commonly be recommended for cysts of 6 cm or more diameter. The vagina and particularly the cervix are inflamed and multiple petechiae can be seen, giving the cervix a strawberry-like appearance. Other higher dose formulations are available overseas and may also inhibit ovulation. A pronounced bradycardia will be present if there is excessive parasympathetic outflow. A loading dose of magnesium sulfate (4 g = 8 mL of a 50% solution given intravenously over 15 minutes) is followed by a continu ous infusion (1 to 2 g per hour = 2 to 4 mL of a 50% solution). Plasminogen is converted to plasmin by plasminogen activators r the presence of a clot in the bladder causes the release of additional plasminogen activators. It may be treated by changing the medication regimen or sensate focus exercises aimed at increasing genital stimulation. The long-term impact of nephrocalcinosis on renal outcome is unclear because data are limited and inconsistent. The base of the flap should be at least 4 cm, while the tip should be at least 3 cm. However, intubation is rarely required if one appro priately uses a mask and one of the devices listed. Women at risk of postpartum cardiovascular decompensation include those with preexisting and acquired ventricular dysfunction. Use of tocolysis beyond this short period does not prolong gestation nor improve neonatal or long-term outcomes. Typical childhood presentation is polyuria, microscopic hematuria, asymptomatic proteinuria, or urolithiasis. Prophylaxis is certainly indicated in the presence of hyperreflexia and some units will use prophylaxis in all cases of severe preeclampsia. This leads to an increase in insulin requirement in prepregnancy diabetics or may lead to the onset of a diabetic condition in pregnancy (gestational diabetes). Superficial lesions commonly arise from the dermis of the shaft or the smooth muscle of the glans penis and usually form subcutaneous-nodules. Milk has been injected into an artery on the donor side of the placenta (black arrow).