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Vice Chair, University of Nevada, Reno School of Medicine

Maternal complications of multiple gestation include abruptio placentae treatment guidelines for back pain generic 50 mg elavil overnight delivery, placenta previa pain treatment video order elavil 10 mg visa, preeclampsia, anemia, hyperemesis gravidarum, pyelonephritis, cholestasis, postpartum hemorrhage, and an increased operative delivery rate. The placenta at term is flat, cake-like, round or oval, 15 to 20 cm in diameter, and 2 to 3 cm in breadth at its thickest parts. Oversized placentas (placentomegaly) are found in cases of erythroblastosis and syphilis and sometimes without evident reasons. The maternal aspect of the normal placenta is lobulated, because short decidual septa separate the major cotyledons. The lobulation may be accentuated, as in erythroblastosis, or obliterated for unknown reasons. The margin of the normal placenta, where decidua, chorionic plate, and fetal membranes meet, appears as a gray, opaque ring caused by the underfolding of membranes and the decidua marginata. This structure pursues a tortuous, irregular course around the margin of the placenta. This sinus provides the major drainage of maternal blood from the hemochorionic interface. The underfolding of the membranes seldom exceeds 1 cm, but in cases of placenta circumvallata it might be quite extensive, and the underlying villi might have degenerated or become ischemic, resulting in a premature delivery of a stillborn fetus. However, even though the chorionic plate may be markedly decreased in size owing to an extensive underfolding, the chorionic villi are usually well vascularized, and this placental variety may have no clinical significance. Cross-sectioning of gently handled and properly fixed placentas exposes this difference and also permits the recognition of intraplacental thrombosis and fibrin deposition quite frequently present in these venous areas. The fibrin depositions, incorrectly called "white infarcts," appear as white laminated nodules. A few subchorionic nodules of fibrin and scattered flecks of gritty calcification are found frequently at term and have no recognized clinical or pathologic significance. The cytotrophoblast has disappeared Microscopically, a villus of a normal placenta consists of a core of collagenous stroma containing well-filled capillaries; these often bulge from the surface of the villus, bringing the fetal blood very close to the maternal bloodstream, separated by only a thin layer of fetal capillary endothelium and the thinned, stretched-out cytoplasm of the syncytial cells. In multiple pregnancy either more than one placental mass or one placenta, but with more than one amniotic sac, may be found. Rarely are both twins in one amniotic sac (monoamniotic monochorionic twins), and these carry a 50% fetal mortality due to cord entanglement or conjoined twins. Separated from the main placental mass, small accessory lobules of placental tissue occasionally may be situated in the membranes. This condition is believed to be caused by atrophy of a previously normal artery, most often the left. When the fetus dies in utero, the cord and fetal membranes (but not the placenta) present postmortem changes comparable to those found in the fetus. Occasionally, an umbilical vessel ruptures, with formation of a hematoma in the cord, membranes, or chorionic Succenturiate placenta Circumvallate placenta Battledore placenta Velamentous insertion of cord plate, during the third stage of labor when such an event causes no harm. If a low uterine implantation has occurred, and if the membranes with the large umbilical branches have grown across the internal os (vasa previa), serious bleeding may occur during the last trimester or with rupture of the fetal membranes during labor. In normal pregnancies, the delivered decidua vera is scanty and is apt to be present in patches. This is associated with potentially catastrophic maternal bleeding and obstruction of the uterine outlet. In the partial and total varieties of placenta previa, a slight degree of separation of the placenta is inevitable when the lower segment of the uterus distends, and hence a certain degree of bleeding is bound to occur. The condition is much more frequent in multiparas than in primiparas, in older patients (older than 35: 1%; older than 40: 2%), with a prior cesarean delivery (two to fivefold increase), in smokers (twofold increase), following in vitro fertilization, and in multiple gestations. It has been suggested that defective vascularization of the decidua, as the result of inflammatory or atrophic processes, may be a contributing factor for placenta previa. Under these circumstances, the placenta is forced to spread over a wide area in order to obtain sufficient blood supply. It is also possible that a multiplicity of factors contributes to lower implantation of the ovum with extension of the placenta toward the internal os. The symptoms of placenta previa include painless hemorrhage (70% of cases), which usually appears after the seventh month of gestation. The hemorrhage may come at any time, without warning and even when the patient is asleep. Separation of small areas and tears in the vessels may occur as the consequence of stretching of the uterine walls, especially the distended lower segment.

The lymphatics from the right testis drain mainly to the right paracaval nodes pain treatment for carpal tunnel cheap elavil 10mg free shipping, including precaval aan neuropathic pain treatment guidelines buy elavil 50 mg line, postcaval, lateral caval, and interaortocaval retroperitoneal lymph nodes. The pelvic organs receive a blend of these two autonomic nerve types through several pelvic ganglia. This autonomic innervation is demonstrated diagrammatically here, with a complete description of the anatomic and functional connections found elsewhere in this Collection. After passing through the sacral foramen, they (nervi erigentes) enter the pelvic nerve plexus (inferior hypogastric) and follow blood vessels to visceral organs, including the descending and sigmoid colon, rectum, bladder, penis, and external genitalia (see table). The pudendal nerve traverses the pelvis adjacent to the internal pudendal artery (see Plate 2-6) and is distributed to the same organs as the vessel supplies. These muscles are important for somatic nervous system control of expulsion of the ejaculate that occurs with ejaculation. The genital branch of the genitofemoral nerve supplies the cremaster and dartos layers of the scrotum and is responsible for the cremasteric reflex that can be compromised with swelling of the spermatic cord as a consequence of testis torsion. The unstriated muscle in the dartos fascia is innervated by fine autonomic fibers that arise from the hypogastric plexus and reach the scrotum along with the blood vessels. Three nerves converge in the spermatic cord and innervate these organs: First, the superior spermatic nerve that penetrates to the interior of the testicle and supplies it and associated structures. Second, the middle spermatic nerve takes origin from the superior hypogastric plexus and joins the vas deferens at the internal inguinal ring and supplies mainly the vas deferens and epididymis. Recent research indicates that the pressure on the male perineum when sitting on a standard bicycle saddle is sevenfold higher than that observed sitting in a chair. It is thought that this increased pressure compresses either the perineal and dorsal nerves or the perineal and dorsal arteries, leading to perineal numbness and erectile dysfunction. Scrotal pain is likely perceived by the genital (external spermatic) branch of the genitofemoral nerve. Pain in the testis proper is referred to its point of origin in the retroperitoneum by referral through the superior spermatic nerve. Pain associated with renal stones may be perceived as arising from the testicle because both the testicle and kidney, including the renal pelvis, receive autonomic fibers from the same preaortic autonomic plexus near the renal arteries. The fascial relationships among tissues in the penis are not emphasized here but can be found in Plates 2-2 through 2-4. The pendulous, or penile urethra, and bulbous urethra extend through the center of the spongy tissue called the corpus spongiosum that joins with the paired corpora cavernosa to form the penile shaft. Each of the three spongy bodies is enclosed in a fibrous capsule, the tunica albuginea (see lower portion of Plate 2-3). The spongy tissue of the corpora cavernosa and spongiosum is composed of large venous sinuses that become widely dilated and engorged with blood during penile erection. From the bladder neck to the triangular ligament (pars prostatica), the funnel-shaped coning of the trigone as it progresses distally into the prostatic urethra, the epithelium is transitional in character. The epithelium of the penile urethra (pars cavernosa) is composed of pseudostratified and columnar cells. The urethral mucosa is surrounded by the lamina propria that consists of areolar tissue with venous sinuses and bundles of smooth, unstriated muscle. Within the penile periurethral tissue are many small, branched, tubular glands, the epithelia of which contain modified columnar, mucus-secreting cells. These lacunae and glands may become chronically infected following urethritis, resulting in recurring symptoms and urethral discharge. The ducts of these glands, about an inch long, pass obliquely forward and open on the floor of the bulbous urethra. The secretions from these glands form part of the seminal fluid during ejaculation. Upon sexual stimulation, nerve impulses release neurotransmitters from the cavernous nerve terminals and relaxing factors from penile endothelial cells result in an erection. Nitric oxide released from parasympathetic nerve terminals is the principal neurotransmitter for penile erection. Concomitantly, there is (2) relaxation of the cavernous sinusoidal smooth muscle within the paired corporeal bodies, facilitating rapid filling and expansion of the sinusoids.

Respiratory depressants are also hazardous because they may cause breathing to stop completely pain management for dogs with hip dysplasia purchase elavil 75 mg free shipping. An individual with kyphoscoliosis who was dyspneic on exertion before an acute episode of cardiorespiratory failure can be expected to return to that condition after the crisis has passed the pain treatment center of the bluegrass cheap elavil 75 mg otc. For many patients who have severe kyphoscoliosis, modest arterial hypoxemia and slight hypercapnia may remain. A domelike structure, it consists of muscular and tendinous elements having their origin in costal, sternal, and lumbar sources. Foramen of Bochdalek hernias constitute approximately 90% of diaphragmatic hernias in infants and young children; the left side is involved in 85% of cases, and 5% are bilateral. In left-sided cases, the stomach, portions of the small and large intestines, the spleen, and the upper pole of the kidney may herniate through the defect into the pleural cavity and ascend freely to the apex of the chest. The presumptive diagnosis can be made from the occurrence of cyanosis and dyspnea soon after birth in infants in whom the cardiac impulse is abnormally sited. In addition, peristaltic sounds may be heard in the thorax, and at the same time, the abdomen is found to be soft and scaphoid in contour. Hernias that occur on the right side may be confused with segmental collapse or pleural effusion. However, the posterior location of the mass in the lateral projection and the shift of the heart are helpful findings. Further antenatal interventions have been based on the discovery that obstructing the normal egress of fetal lung fluid enlarges the lungs, reduces the herniated viscera, and accelerates lung growth in experimental models. Temporary occlusion of the trachea has been achieved by external clips and more recently by internal balloon plugs. Appropriately designed randomized trials are required to determine whether such interventions improve long-term outcome. Congenital defects in the anterior parasternal region (Laney space) may result in the formation of a foramen of Morgagni hernia. These hernias are usually right sided, and most commonly involve the liver and omentum. Anterior hernias are usually asymptomatic in the neonatal period, but when diagnosed coincidentally on a chest radiograph, they should be repaired because strangulation of the abdominal organs may occur. Variations of tracheoesophageal fistula and rare anomalies of trachea Most common form (90% to 95%) of tracheoesophageal fistula. Upper segment of esophagus ending in blind pouch; lower segment originating from trachea just above bifurcation. Postnatally, the diagnosis can be suspected in a newborn infant who has excessive mucus and cannot handle his or her secretions adequately. Formerly, the diagnosis was made by using a contrast study with barium or Gastrografin (meglumine diatrizoate); however, there is the danger of aspirating these materials into the lungs. On the chest radiograph, it will be noted that the tip of the catheter is usually opposite T2-T3. Radiography will show the typical esophageal obstruction, and the contrast material should then be immediately aspirated. During this time, the infant is fed through a gastrostomy, and the upper pouch is kept clear of secretions. When abnormal bifurcations are present, the right upper or left upper lobe bronchi (or both) arise independently from the trachea. The localized form is caused by a web of the respiratory mucosa or by excessive growth of tracheal cartilage. Sixty percent of patients with agenesis of the lung are found to have other congenital anomalies. The most frequently associated anomalies are patent ductus arteriosus, tetralogy of Fallot, anomalies of the great vessels, and bronchogenic cysts. There are many causes of secondary lung hypoplasia, including a reduction in amniotic fluid volume, reduction in intrathoracic space, reduction in fetal breathing movements (neurologic abnormalities or neuromuscular disorders), genetic disorders (trisomy 18 or 21), malnutrition (vitamin A deficiency), maternal smoking, and medications such as glucocorticoid administration. Only rudimentary bronchi on left side, which end blindly Hypoplasia of left lung Hypoplastic lung contains some poorly developed bronchi but no alveolar tissue affected side together with the absence of the pulmonary artery.

It then passes through an aperture between the arcuate ligament of the pubis and the anterior border of the transverse pelvic ligament (see Plate 2-5) pain disorder treatment cheap 10 mg elavil otc. The deep dorsal vein then divides into branches that join the prostatic venous plexus tailbone pain treatment home remedy buy elavil 25mg otc. This plexus of thin-walled veins, with similar veins from the bladder and rectum, communicate freely with one another and with adjacent venous tributaries. The internal spermatic artery joins the spermatic cord above the internal inguinal ring and lies adjacent to the testicular veins (pampiniform plexus) to the testis mediastinum. This artery forms a network over the tunica vaginalis and usually anastomoses at the testicular mediastinum with the internal spermatic and deferential arteries. The external spermatic artery also forms anastomotic patterns that supply the scrotal wall. The veins of the spermatic cord emerge from the testis mediastinum to form the extensive pampiniform plexus. With varicocelectomy, all veins except the deferential veins are ligated to reverse this process and improve pain or testis function. When performed in the retroperitoneum (Palomo or laparoscopic), varicocele recurrence rates after surgery are higher than when performed inguinally or subinguinally because of more complete ligation of all suspicious contributing veins observed more distally. Because of the increased number of pampiniform plexus veins subinguinally and the potential lack of a sufficiently collateralized arterial supply, varicocelectomy at this anatomic level is performed microscopically. They then circle the corona, and the vessels from both sides unite on the dorsum to accompany the deep dorsal vein beneath Buck fascia. Glans penis lymphatics may also terminate in the deep inguinal lymph nodes and the presymphyseal node located anterior to the symphysis pubis. The bulbous and membranous urethra drain through channels that accompany the internal pudendal artery and terminate in the internal iliac or hypogastric (obturator) nodes that are associated with the branches of the internal iliac (hypogastric) arteries or in the external iliac nodes. Nodal metastases from testicular tumors in these nodes Presymphyseal node Lymphatic drainage from prostate Preaortic node Promontorial node Common iliac node External iliac nodes Obturator nodes Pathway along inferior vesical vessels to internal iliac nodes (principal pathway) (Middle and lateral) sacral nodes Internal iliac nodes Pathway alongside rectum to (middle and lateral) sacral nodes Pathway over bladder to external iliac nodes Prevesical plexus and pathway (broken line) to external iliac nodes Pathway (broken line) from lower prostate and membranous urethra along internal pudendal vessels (beneath pelvic diaphragm) to internal iliac nodes indicate probable involvement of the epididymis, because the lymphatic drainage of the testis follows the internal spermatic vein through the inguinal canal to the retroperitoneal space. These events effectively trap blood within the corpora cavernosa and raise the penis from a flaccid to an erect position (tumescence phase). Both masturbation and sexual intercourse trigger the bulbocavernosus reflex (see Plate 2-11) that causes the ischiocavernosus muscles to forcefully compress the blood-filled corpora cavernosa. Detumescence results when erectile neurotransmitter release stops, when phosphodiesterases break down second messengers, or as a result of sympathetic discharge during ejaculation. In fact, significant erectile dysfunction precedes heart attacks and stroke events by 5 to 7 years. Hormonally, androgen deficiency causes a decrease in nocturnal erections and decreases libido. Recommended laboratory tests include urinalysis, complete blood count, fasting blood glucose, lipid profiles, and testosterone. Cardiovascular risk factors should be determined and an appropriate referral made if these risks exist. This is among the most common birth defects of the male genitalia, second only to cryptorchidism, but the incidence varies widely from country to country, from as low as 1 in 4000 to as high as 1 in 125 boys. The global incidence of hypospadias has increased since the 1980s and this has been attributed to the wider application of assisted reproductive techniques and to endocrine disruptors. As it is considered to represent a degree of feminization or male pseudohermaphroditism (see Plate 1-13), hypospadias has also been associated with hypogonadism. In penile or second-degree hypospadias, the urethral meatus is situated more proximally on the penile shaft. In perineal or third-degree hypospadias, the urethral opening is proximal to the penile shaft and is observed on the scrotal or perineal skin. With hypospadias, the prepuce is usually redundant and forms a hood over the glans. Early correction of the chordee is important so that the penis and corporal bodies may grow straight.