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Stress incontinence predominates, but many patients also complain of frequency, urgency or urge incontinence. Education and reassurance is an extremely important facet of the care provided to these couples. A significant proportion of chronic urticaria is triggered through particular physical stimuli. Differential Diagnosis Lipoma Epidermoid Teaching Points Dermoid and epidermoid inclusion cysts of the orbit are choristomas arising from congenital epithelial remnants. Early performance of tracheostomy (sometimes as early as within the first week of mechanical ventilation) has been proposed in patients expected to require prolonged mechanical ventilation; however, the value of this practice has not been proven. The pudendal nerve gives rise to the inferior hemorrhoidal nerve, the perineal nerve, and the dorsal nerve of the clitoris. There is no need to augment her contractions with oxytocin in this stage of labor. These chromosome abnormalities are detected by obtaining a karyotype on the male and female partners. A Microbiology the vaginal flora play a critical role in vaginal defenses by maintaining the normally acidic pH (3. This happens until about the tenth week of gestation after which time the placenta takes over progesterone synthesis. Antihypertensive therapy is unlikely to benefit a pregnancy complicated by mild hypertension. Early compared with late neuraxial analgesia in nulliparous labor induction: A randomized controlled trial. In rabbits, the withdrawal of progesterone is followed by the prompt evacuation of the contents of the pregnant uterus. Symptoms may recur and be most prominent just before menses or in association with intercourse. There are many tests which have been recommended in the evaluation of women who have experienced three or more pregnancy losses. Immediately after birth, constriction then closure of the ductus arteriosus, also increases pulmonary blood flow. The connective tissue is looser there, and the needle need not be fanned in to digital septa as described earlier. It is made at the end of the second stage of labor just before delivery, when indicated. Superb nursing care and physical therapy are essential to prevent early and late fatal complications. While uterine atony is the most common cause of immediate postpartum hemorrhage, retained placental fragment must be considered in delayed postpartum bleeding. Thyroid-stimulating hormone testing every 5 years beginning at the age of 50 years. Treatment of maternal infection with sulfonamides or pyrimethamine (after the first trimester) is indicated. To look for infection, vaginal swabs should be taken, using a sterile speculum if the membranes have ruptured. Mastectomy is surgical removal of both the tumor and the healthy, "at risk," residual breast tissue. Radiotherapy may be used to shrink large tumours prior to surgery, postoperatively if groin lymph nodes are positive, or palliatively to treat severe symptoms. All anesthetizing locations where local anesthetics are used must have intralipid readily available. Women should be asked to complete menstrual diaries, recording their moods and other symptoms for at least two cycles. Local spread, especially to regional lymph nodes, is common at the time of presentation. Fat emboli to the brain may be a cause of sudden neurologic deterioration from injury to the gray and white matter, which may be severe enough to produce coma.

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Microscopically, the ova or schistosome is seen surrounded by a granulomatous reaction with giant and epidermoid cells. Most respiratory problems result from airway obstruction and can be resolved with simple maneuvers, such as head repositioning or jaw thrusts. Chemotherapy and radiation therapy do not typically alter patient outcomes, but radiation therapy is occasionally used in patients with recurrent tumors. A radical hysterectomy is reserved for patients with cancer and is too radical of a procedure for a preinvasive lesion, and is not without complications. If scalp sampling is impossible, or the fetal heart shows a sustained bradycardia, delivery is undertaken anyway. Hysterosalpingogram, sonohysterogram, or hysteroscopy to evaluate the uterine cavity. If a patient is diagnosed as having a rubella titer of less than 1:8, she should be immunized postpartum. Outpatient hysteroscopy, under paracervical local anaesthetic block, can also be performed. Stimulating conversion of androgens to estrogens within the granulosa cell by the enzyme aromatase. Further studies are needed before this therapy should be incorporated in to standard of care. D Breast pain Women commonly seek advice from physicians for breast pain (also known as mastalgia or mastodynia), which may be cyclic or noncyclic in nature. Uterine muscle fibres contract to compress the blood vessels formerly supplying the placenta, which shears away from the uterine wall. There is minimal reticulation in the surrounding fat, and there are none of the typical inflammatory features seen in pyogenic adenitis. While migraine with aura is a contraindication to the use of birth control pills, there are no contraindications except for current pregnancy to the use of emergency contraception. If symptoms persist after 2 weeks, reinfection could be present and retreatment should be considered, especially if live mites are observed. Diastematomyelia is classified on the basis of the dura: Type I: Two distinct dural sacs. Typical symptoms include headache, nausea, vomiting, cranial nerve palsies, back pain, and radicular pain. Fourth-degree lacerations are extensions of the third-degree tear through the rectal mucosa to expose the lumen of the rectum. Other patients fail to get any better, and some others develop hemorrhagic conversion or a large intracerebral hematoma. Note the mylohyoid (white arrowheads) on the coronal images, which separates the sublingual and submandibular spaces. Advancing age, obesity and an underlying thrombophilia significantly increase the risk. When the baby takes his first breath, resistance in the pulmonary vessel circuit is substantially reduced, and thus blood can flow through the pulmonary artery to the lungs (instead of to the aorta through the ductus arteriosus) to become oxygenated. Uterine size is defined as the equivalent gestational size as determined by abdominal and pelvic examination. The vaginal ring is worn continuously for 3 weeks and then discarded; a new ring is inserted in to the vagina 1 week later. In the primary stage, infected individuals have not had sufficient time to mount an immune response that can be serologically detected. These can include changes in cycle frequency, duration, and amount of blood flow which can be classified as normal or abnormal. Intravenous or intramuscular oxytocin (10 U intramuscularly or 20 U in a 1,000-mL intravenous bottle), ergonovine (0. Differential diagnosis includes tinea corporis, pityriasis alba, pityriasis rosea, vitiligo, leprosy, and secondary syphilis. This risk may be acceptable for some women who would rather not experience surgical menopause at a young age. Women who are more than 50 lb overweight have a ten times higher risk of developing endometrial cancer over normal-weight individuals. Subdural hematomas are the most common intracranial manifestations in nonaccidental trauma. After lateral dissection around the urethra, the tape is introduced vaginally with the trocars entering the retropubic space.

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Metastases are more likely to involve the posterior pituitary, produce diabetes insipidus, and may destroy bone. The former are important in menstrua tion and in nourishment of the growing fetus. These anomalies arise from failure of the embryologic precursors of the reproductive tract to develop normally (see Chapter 21). B A multidisciplinary approach, including social workers, is essential; substance abusers probably have nonmedical problems that tend to complicate pregnancy. In reality hypoxia is simply the best known cause of intrapartum fetal damage and its effects are unpredict able and vary considerably. The major ethical question in some patients reaching this stage is whether a neurosurgical procedure is justified in a situation that may be hopeless and in which surgery may afford only minimal gain in survival with poor quality of life. John Sampson in the early 20th century, postulates that the retrograde flow of menstrual debris through the fallopian tubes causes the endometrial cells to spread in to the pelvis, form implants there, or serve as irritative foci, which stimulate coelomic metaplasia and differentiation of the peritoneal cells in to endometrial-type tissue. Occasionally, intravenous sedation may be necessary to accomplish a thorough genital examination. The septum can also have a microperforation allowing egress of menstrual blood and presents as a shortened vagina with no visible cervix. However, the risk does increase after two consecutive miscarriages to 17% to 31%, and after three miscarriages the risk increases to 25% to 46%. Hypervolemia is not sufficient to produce a sustained increase in cerebral blood flow and perfusion. While a woman with abnormal glucose tolerance may be more likely to develop increase amniotic fluid volume (polyhydramnios), repeating prenatal labs and a one-hour glucose tolerance test now will not be helpful in confirming that the fundal height measurement is lagging. In the normal woman, the bladder neck is equally compressed so that the pressure difference is unchanged. Of those women who achieve pregnancy after an ectopic pregnancy, as many as 27% will have another ectopic pregnancy. The following percentages reflect the prevalence of these factors in infertility evaluations. She is measuring size greater than dates and you perform an ultrasound that differs by 18 days. Mortality, although rare, does occur, particularly in neglected cases in which a ruptured tuboovarian abscess can lead to septic shock and death. Uric acid levels tend to be lower in women, probably on the basis of the uricosuric effect of estrogen. Performance in school: affords a picture of the home environment, intellect, and general well-being. George Papanicolaou developed a method of identifying abnormal cells in exfoliative cytology in the 1920s and published his work in the 1940s. This drug is considered safe outside of the first trimester; however, the patient should be counseled regarding available literature on the association of this drug and congenital heart defects or other anomalies. Her hypertension and proteinuria suggest that she has mild preeclampsia, but at this time, she does not satisfy the criteria for severe disease. The fetal thyroid starts to be functional at the end of the first trimester and fetal thyroxine levels steadily increase from midgestation until term. The extraskeletal associations of vitamin D deficiency include diabetes, autoimmune disorders, cardiovascular disease, and cancer. Radiation therapy, although useful for the reduction of mass effect in the longer term, is characteristically associated with worsening inflammatory edema in the early phase. A guarded attitude toward these massive cerebral infarcts is understandable, but surgical treatment may be beneficial in some cases. These children are at risk for behavior and school problems, substance abuse, and violent relationships as adults. Most women with leiomyomas are asymptomatic; symptoms occur in 10% to 40% of patients. Thus, blood flowing in to the right ventricle is not as well oxygenated as blood coming directly from the placenta.

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If the lesions are left untreated, buboes and inguinal ulcers may develop 1 to 2 weeks after the ulcers appear, accompanied by regional lymphadenopathy. Antibiotics alter the microbiology of the vagina and can increase the risk of infection. Vasa previa is a condition associated with velamentous cord insertion where fetal vessels in the membranes cross the region of the cervical os. In one study of critically ill neurological patients the combination of absent corneal reflex, absent cough reflex, and extensor or absent motor responses predicted respiratory/circulatory arrest within 60 minutes of extubation in 85% of cases. Patients have varying degrees of fusion of the hemispheres, basal ganglia, hypothalami, and thalami. Late-onset congenital adrenal hyperplasia (1) the production of excess androgen is stopped by glucocorticoid therapy; steroid replacement should correct the androgen excess with return of menstrual cyclicity. Peritoneal injury results from the inflammatory cascade that is precipitated by infection, endometriosis, and operative procedures (70% of cases). In individuals with diabetes, adrenergic symptoms (tremors, tachycardia, anxiety, agitation) and cholinergic symptoms (excess sweating and hunger) can arise in roughly the range of 65 to 70 mg/dL. The source of sepsis was eventually recognized to be ventilator associated pneumonia. A physician must inform patients of the possible side effects and explain the alternative methods of contraception. H ow do you safely get a patient with a recent flare-up of myasthenia gravis off the ventilator and keep him off the ventilator For one thing, management of myasthenic crisis with neuromuscular respiratory failure remains poorly defined and largely empirical. Osteopenia: Osteoporosis: Osteoporotic fractures Sexual problems Sexual problems affect about half of all women and become more common with age. Antibiotic prophylaxis to reduce peristomal infection is administered, and feeding can be started 24 hours or less after placement. Ideally, treatment center options should include individual and group counseling, intensive day treatment, and residential treatment. Most surgeons anticipate "trouble ahead" when mobile atherosclerotic plaques are found or prolonged hypotension has occurred during major vascular surgery, and both are strong indicators the brain could have been affected. A 24-year-old female comes in for a new patient visit with the complaint of missed menstrual cycles. The diagnosis should be reviewed after 24 h if there is no significant improvement and a laparoscopy performed. If induction of labor is considered before 39 weeks, assessment of fetal lung maturity by amniocentesis should be performed to assess the lecithin-to-sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol in the amniotic fluid. Proper counselling concerning risks, social support and pregnancy monitoring are required. Vulvar irritation or burning is a symptom associated with a variety of disorders, including vulvovaginitis, vulvovestibulitis, and vulvodynia. Secondary lymphoma (from other sites) more often involves the leptomeninges and dura. A 26-year-old woman, gravida 2, para 1, at 39 weeks of gestation, is admitted to the hospital in labor with ruptured membranes. The obstetric history Personal details Ask her name, age, occupation, gestation and parity. The risk of malignancy is small enough not to warrant routine removal or moni toring. Perform cordocentesis when it is believed that the fetus is at risk for severe anemia. Ipsilateral inguinal and femoral lymphadenectomy may be considered when the lesion is well lateralized. Management Excision of tract and cord untethering is performed when these lesions are symptomatic. After the withdrawal bleed, cyclic therapy with once-a-day administration is continued for 3 months to reduce the endometrial lining to baseline levels. As procedure-related morbidity and mortality rates decreased with advances in anesthetic and operative techniques, the rate of primary cesarean sections increased.

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Pathology and sites of fibroids the sizes vary from a few millimetres to massive tumours filling the abdomen. Consequently, it should be suspected when a febrile patient develops confusion or drowsiness associated with seizures or focal deficits referable to those locations. Physical examination: uterine size, texture and mobility, presence of fibroids or adenexal masses, nodularity along the uterosacral ligaments B Imaging studies are useful in determining the etiology of pelvic pain. Most women with premature menopause undergo premature oocyte atresia and follicular depletion. A 25-year-old gravida 5, para 4, woman rapidly delivered an infant weighing 3,900 g upon presenting to the labor and delivery unit without any anesthetic. Which of the following medications is the most appropriate therapeutic in this situation She would like to know which of the following is increased in patients with epidural analgesia A Prolonged labor B Cesarean delivery C Neonatal depression D Cerebral palsy E Episiotomy 8. Premature birth is a risk factor with teenage pregnancies, not advanced maternal age pregnancies. Dysfunctional bleeding, however, is defined as a disruption in ovulation and therefore causes a change in the length of the menstrual cycle or leads to an unpredictable and irregular bleeding pattern. They may engulf the basilar artery and may obstruct (but not invade) the fourth ventricle. D&C is also required when an endometrial biopsy cannot be performed in the office; this is usually the case if a woman has a stenotic cervical os, making it impossible to pass the biopsy catheter. This bleeding usually begins 7 to 14 days after the missed menstrual period, and patients may interpret the bleeding as a menses. C Structural causes of abnormal uterine bleeding include fibroids, endometrial polyps, adenomyosis, and malignant tumors of the uterus including sarcoma or endometrial cancer. Symptoms may arise from ventricular obstruction (headache, nausea, obtundation) or neural compression (focal deficits). Longitudinal fractures are the most common, with transverse fractures the least common, occurring in 5% to 20% of cases. Antenatal Care 149 Planning pregnancy care the doctor or midwife advises the woman of the most appropriate type of antenatal care, and a plan for visit frequency, extra surveillance or intervention is made. If patients have been treated with therapeutic hypothermia or if there has been ischemic liver injury after cardiopulmonary resuscitation, it will be very difficult-if not actually impossible- to exclude a lingering sedative effect. Less common in girls than boys; there is often a family history of delayed puberty. The information gained may be used to diagnose and manage a variety of conditions that are described elsewhere in this book. Fibroids in a submucosal location are believed to cause miscarriages because of inadequate blood supply if the placenta implants on the fibroid. In fact, withholding or withdrawing treatment is a common reason for consulting the medical ethics committee. Contingent sequential screen-if the first-trimester portion shows low risk, the patient will have completed her screening; if the first-trimester risk is elevated, invasive diagnostic testing will be recommended; if the first-trimester risk falls in an intermediate zone then the secondtrimester part of the screen is performed. Because of its high transmissibility as a blood-borne pathogen, women who have received multiple blood transfusions prior to 1990 should be screened. The perpetrator (and for that matter the victim) may have grown up in a family, peer group, or culture in which sexual aggression is part of the definition of manhood. The constellation of symptoms is due to an enzymatic defect which disrupts the normal pathway converting cholesterol to sex steroids and mineralocorticoids. Nongerm cell origin (1) Lipoid cell tumors (estrogen producing) (2) Granulosa-theca cell tumors (estrogen producing), of which approximately 20% are malignant b. The aetiology of prolonged pregnancy is not understood, but it is more common if previous pregnancies have been pro longed and in nulliparous women, and is rarer in South Asian and black women. Since coinfection with chlamydia is common, treatment for chlamydia in conjunction with treatment for gonorrhea should be considered unless chlamydia infection has been ruled out. However, since only two out of the three criteria are necessary presentation can vary. Prescription database studies have yielded conflicting results when rosiglitazone is compared to pioglitazone, with the most recent database analysis suggesting comparable cardiovascular events between rosiglitazone and pioglitazone. After transfer to our emergency department, there was clear evidence of further neurologic deterioration, mainly decline in responsiveness with eye opening to voice only, impaired vertical eye movements, marked dysarthria, and flaccid hemiparesis. If anaemia is suspected, fetal blood sampling is performed under ultrasound guidance, using a needle in the umbilical vein at the cord insertion in the placenta, or in the intrahepatic vein.

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This device consists of a metal cup (40 to 60 mm in diameter) that is applied to the fetal scalp. In more severe cases, radiation therapy or surgical decompression of the orbit is performed. Conjugated equine oestrogens are derived Tibolone Tibolone is a synthetic steroid compound that is inert but is converted in vivo to metabolites with oestrogenic, progestogenic and androgenic actions. Preventive measures include prophylactic oophorectomy, which should be offered to high-risk patients. The site of cortical breakthrough lies below the insertion of this muscle on the mandible. Fetal abnormality Where one twin has an abnormality selective termination should be discussed. Metabolic syndrome is a constellation of cardiovascular disease risk factors associated with insulin resistance. Overall, when there are favorable anatomic features, the surgery is successful in 75% of patients. Up to 94% of genital warts have been shown to be eradicated with application of podophylotoxin. Anesthetic management during cesarean delivery that does not result in a depressed neonate or in harm to the mother. The vestibule is the space between the labia minora extending from the clitoris to the vaginal introitus. The most salient issue about the evaluation of unexplained encephalitis is how much of it may be without results-an intimidating assignment to say the least. Disc space narrowing is seen with collapse and destruction of the adjacent vertebrae, which allows disc material to herniate in to the endplate. These medications are administered orally for 5 days just like clomiphene citrate. Drainage of ascitic fluid is occasionally necessary to increase comfort and, by reducing splinting of the diaphragm, ease breathing. Most physicians would prefer an aggressive approach in patients who have had rapid progressive motor symptoms and use a high dose. This phenomenon is known as "menstrual magnification," and occurs in both medical conditions, such as migraines, as well as psychiatric disorders, such as depression and anxiety disorders. Sending a patient home without further work up for size less than dates would not be appropriate. Because first trimester bleeding must be worked up until intrauterine pregnancy is confirmed, sending this patient home without confirming her pregnancy stage and status is inappropriate. E Musculoskeletal disorders Pain is most commonly due to repetitive stress and strain associated with the typical pelvic pain posture, increased lumbar lourdosis and anterior tilt of the pelvis. Naloxone is capable of reversing the effects of opioids such as respiratory depression or pruritus. The positions of the arterial border zones vary with large vessel vascular anatomy. Treatment is with magnesium sulphate, and intensive surveillance for other complications. The family brought up his previously expressed strong desire for organ donation if something major would happen to him. The hyperkeratotic surface is reduced using a scalpel blade; then liquid nitrogen is applied to the wart using a cotton-tipped applicator until a 1- to 2-mm zone of frozen tissue is created and maintained around the lesion for about 5 seconds. The resulting hyperinsulinemia continues to stimulate ovarian steroidogenesis and increases production of androgens. Presence of ultrasound abnormalities will potentially increase the risk of chromosomal, syndromic, or structural abnormalities. They are also seen, often as a recurring event, in the periareolar region of nonlactating women, or as isolated peripheral infections in postmenopausal or immunocompromised patients.

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Flash pulmonary edema is usually a result of increased sympathetic activation due to an acute medulla oblongata lesion or due to a rapidly increased intracranial pressure. These changes can be due to many causes, including hormonal fluctuation, medications, sleep disturbance, loss of partner, and life stresses. She died of a cardiac arrhythmia after the family had requested a do-notresuscitate order. Normally, the tubes facilitate collection and transport of the oocyte and embryo in to the uterus. The cervical canal is usually occluded by fibrosis after endometrial resection, cone biopsy or by a carcinoma. There are several ways to approach this clinical problem medically and surgically (Table 10. These insulin sensitizers have been shown to improve androgens and insulin resistance and include rosiglitazone and pioglitazone. Fibroids are common in the peri menopausal woman and may be incidental: menstrual problems may also be the result of hormonal irregulari ties or malignancy. The goal of treatment is to prevent cirrhosis and subsequent sequelae of chronic liver disease. The most recent estimate for the prevalence of the metabolic syndrome is approximately 25% of the general U. Agents used for cervical ripening: (1) Hormonal: Prostaglandin E1 (Misoprostol, aka cytotec), Prostaglandin E2 (Dinoprostone, aka Prepidil gel, and cervidil insert) Note: Prior c-section is a contraindication to use of these above hormonal ripening agents. A 20-year-old woman just delivered a viable male neonate at 38 weeks of gestation after being a restrained passenger in a car accident. This procedure involves en bloc removal of the uterus, cervix, upper third of the vagina, parametrium, and uterosacral and uterovesical ligaments. Vellus is soft, fine, unpigmented hair that covers apparently hairless areas of the body. The grief experienced by a couple affected with this disorder is often compounded by frustration due to the fact that many will have an evaluation that reveals no identifiable cause of their pregnancy losses. Careful genetic counseling is needed and amniocentesis or percutaneous blood sampling maybe recommended. The typical lymphangioma is multi-septated and involves multiple compartments in the neck. Estrogen stimulates the proliferation and maturation of vaginal epithelial cells, whereas progesterone is inhibitory. If a polyp is evident, it is avulsed and sent for histology: this is normally possible without anaesthesia. As a result there is decreased lubrication which leads to subsequent irritation and pain with sexual activity. The dose should be adequate, and failure to prescribe the right dose is a common error. Adipose tissue, which contains aromatase, is capable of converting peripheral androgens to estrogens. On physical examination, you note a fundal height of 24 cm, and there are no fetal heart tones on auscultation. Use of diffusion-weighted imaging to evaluate the initial response for progressive multifocal leukoencephalopathy to highly active antiretroviral therapy: Early experience. There is fusion of the frontal lobes anteriorly, and fusion of the thalami in the midline (arrows). When significant pain relief is required, add an analgesic agent, such as morphine or fentanyl. While it is true that this can be explained because these patients start with large areas of ischemia and severe symptoms, there may be other factors apart from recanalization that affect the chances of recovery. Detection of adequate sperm production: semen analysis A normal semen analysis result virtually excludes a male cause for infertility.

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The single greatest risk factor for relationship violence during pregnancy is a history of violence within the year prior to the pregnancy. Carbon dioxide accumulates in the fetal circulation, causing a decline in pH, resulting in acidemia. Breech presentation and transverse or oblique lie in labour are discussed in Chapter 26. Patients present with fever, headache, rapidly progressive cognitive decline, and focal neurologic deficits. This may be the result of malignant change or de novo malignant transformation of normal smooth muscle. Pelvic and abdominal surgeries may also result in peritubal adhesions but have not been directly associated with ectopic pregnancy. Most women with regular cycles are ovulatory, and menorrhagia may result from subtle abnormalities of endometrial haemostasis or uterine prostaglandin levels. Obtaining a pregnancy test is always the first step in the evaluation and management of abnormal bleeding for reproductive age women. The incubation time is 3 to 5 days and there is a 70% chance of infection after exposure. Treating her surgically will improve her pain symptoms more effectively than medical therapy, and will also improve her ability to conceive. Increased risk of hemorrhagic complications in newborns exposed to anticonvulsants in utero. Unilateral ossification is typical for infections that arise from middle ear disease, whereas ossification after meningitis can be bilateral. Hyperandrogenic disorders are usually associated with irregular or absent menstrual cycles. It is seen most in those who wear occlusive footwear because shoes promote warmth and sweating, which encourage fungal growth. Discontinuation of exenatide after 52 weeks of therapy results in a rapid loss (within 4 weeks) of the improvement in beta-cell function, so this therapy needs to be ongoing. Offspring of parents with cardiac disease have an increased risk of developing cardiac disease in their lifetimes. Many of the lesions have a long axis perpendicular to the surface of the ventricles. Fluid volume increases with increasing the gestational age until the middle of the third trimester, after which the volume stays stable and may decrease somewhat at term. The spectrum of spinal lipomas includes intradural lipomas, lipomyeloceles, and lipomyelomeningoceles. In women with asymptomatic placenta praevia, admission can be delayed until 37 weeks or delivery, provided they can get to hospital easily. A 56-year-old woman, gravida 0, para 0, presents to her gynecologist complaining of abdominal bloating. It is important to distinguish a glomus jugulotympanicum from simple glomus tympanicum since the surgical approach is different. Maternal cardiac disease C Refractory preterm labor this condition is defined as persistent uterine contractions and cervical change despite maximal tocolytic therapy. It most commonly occurs following pelvic floor muscle and nerve damage that resulted from pregnancy and childbirth. It may take several minutes for a circulatory arrest to occur (asystole is not a criterion although both often go together). B Recurrence Of those women who achieve pregnancy after an ectopic pregnancy, as many as 27% will have another ectopic pregnancy. It is not infrequent to see patients with encephalitis who exhibit fluctuating levels of alertness and awareness. Symptoms and signs of megaloblastic anemia during pregnancy include nausea, vomiting, and anorexia. Which of the following physiologic changes of pregnancy increases the risk of the inability to place an endotracheal tube in this patient A Increased tidal volume B Edema of the larynx C Nasal congestion D Delayed gastric emptying E Shift of oxygen saturation curve 4.