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Dropping down theory: the fertilized ovum drops down and is implanted in the lower segment cardiovascular disease burden in india order procardia 30 mg with amex. Persistence of chorionic activity in the decidua capsularis and its subsequent development into capsular placenta which comes in contact with decidua vera of the lower segment can explain the formation of lesser degrees of placenta previa capillaries bursting around eyes buy procardia 30 mg with amex. Defective decidua coronary artery perfusion pressure buy procardia 30 mg otc, results in spreading of the chorionic villi over a wide area in the uterine wall to get nourishment. During this process, not only the placenta becomes membranous but encroaches onto the lower segment. Such a placenta previa may invade the underlying decidua or myometrium to cause placenta accreta, increta or percreta (see p. The high risk factors for placenta previa are - (a) Multiparity (b) Increased maternal age (> 35 years) (c) History of previous cesarean section or any other scar in the uterus (myomectomy or hysterecotomy) (d) Placental size (mentioned before) and abnormality (succenturiate lobes) (e) Smoking - causes placental hypertrophy to compensate carbon monoxide induced hypoxemia (f) Prior curettage. The placenta may be morbidly adherent due to poor decidua formation in the lower segment. Umbilical cord-The cord may be attached to the margin (battledore) or into the membranes (velamentous). The insertion of the cord may be close to the internal os or the fetal vessels may run across the internal os in velamentous insertion giving rise to vasa previa, which may rupture along with rupture of the membranes. Lower uterine segment-Due to increased vascularity, the lower uterine segment and the cervix becomes soft and more friable. Currently with ultrasound precision, more accurate placental location is made in relation to the cervical internal os. In the majority, the placenta lies either in the anterior or posterior wall, the latter is more common. This leads to opening up of uteroplacental vessels and leads to an episode of bleeding. Note separation of the placenta, the bleeding is said to be the effective reduction of the anteroposterior inevitable. The blood is almost always maternal, although fetal blood may escape from the torn villi especially when the placenta is separated during trauma. The mechanisms of spontaneous control of bleeding are: (1) Thrombosis of the open sinuses. Placental migration: Ultrasonography at 17 weeks of gestation reveals placenta covering the internal os in about 10% of cases. Repeat ultrasonography at 37 weeks showed no placenta in the lower uterine segment in more than 90% of cases. The term placental migration (though misnomer) could be explained in two ways: (i) with the progressive increase in the length of lower uterine segment, the lower placental edge relocates away from the cervical os (ii) due to trophotropism (growth of trophoblastic tissue towards the fundus), there is resolution of placenta previa. The classical features of bleeding in placenta previa are sudden onset, painless, apparently causeless and recurrent. In about 5% cases, it occurs for the first time during labor, especially in primigravidae. In about one-third of cases, there is a history of "warning hemorrhage" which is usually slight. Chapter 19 Antepartum Hemorrhage 285 the bleeding is unrelated to activity and often occurs during sleep and the patient becomes frightened on awakening to find herself in a pool of blood. Obvious causes for the placental separation such as trauma or hypertension are usually absent.

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Management of normal labor aims at maximal observation with minimal active intervention arteries face 30 mg procardia overnight delivery. The idea is to maintain the normalcy and to detect any deviation from the normal at the earliest possible moment cardiovascular stress test cheap procardia 30mg online. The vulva and the perineum are washed liberally with soap and water and then with 10% Dettol solution or Hibitane (chlorhexidine) 1 in 2 coronary heart yourself discount procardia 30mg mastercard,000. Antiseptic and aseptic precautions are to be taken during vaginal examination and during conduction of delivery. Vulva should once more be swabbed from before backward with antiseptic lotion like 10% Dettol or Hibitane 1 in 2,000. The same solution is poured over the vulva by separating the labia minora by the fingers of left hand. The following informations are to be noted and recorded carefully (Partograph-see p. Color of the liquor in the partograph is recorded as-I: membranes intact; R: membranes ruptured; C: liquor clear; M: liquor meconium stained; B: liquor blood stained. Presenting part and its position by noting the fontanels and sagittal suture in relation to the quadrants of the pelvis. Lambda or Posterior fontanel is recognized by the big "Y" shaped three suture lines. Bregma or anterior fontanel is recognized by diamond-shaped area and the presence of four suture lines. Molding 1: Sutures apposed; 2: Sutures overlapped but reducible; 3: Sutures overlapped but not reducible. Spines are the most prominent bony projections felt on internal examination and the bispinous diameter is the shortest diameter of the pelvis in transverse plane being 10. The levels above and below the spines are divided into fifths to represent centimeters. Assessment of the pelvis especially in primigravidae is to be done, and elasticity of the pelvic floor and presence of vulval varicosity, if any, are to be noted. Pelvic assessment specially in primigravidae should be done during the initial examination. Chapter 13 Normal Labor 157 - the progress of labor can be judged on periodic examinations noting the dilatation of the cervix and descent of the head in relation to the spines (station). Enquiry is to be made about the onset of labor pains or leakage of liquor, if any. Thorough general and obstetrical examinations including vaginal examination are to be carried out and recorded. Records of antenatal visits, investigation reports and any specific treatment given, if available, are to be reviewed. Bowel-An enema with soap and water or glycerin suppository is traditionally given in early stage. Rest and ambulation-If the membranes are intact, the patient is allowed to walk about. Ambulation can reduce the duration of labor, need of analgesia and improve maternal comfort.

A low-molecular-weight lipid-soluble substance with a high concentration gradient across the placenta coronary heart disease history purchase procardia 30 mg line, for example arteries foot discount procardia 30mg on line, will be transferred quickly to the fetus 3 arteries blocked buy procardia online from canada. Actual transfer occurs by simple diffusion, facilitated diffusion, active transport, and/or endocytosis (Table 1. Early changes are due, in part, to metabolic demands brought on by the fetus, placenta, and uterus, and, in part, to increasing levels of pregnancy hormones, particularly those of progesterone and oestrogen. Later changes are more anatomical in nature and are caused by mechanical pressure from the expanding uterus. The posterior pituitary releases oxytocin principally during the first stage of labour and during suckling. Creatinine within the normal range for non-pregnant women may indicate renal impairment in pregnancy. Preparation for pregnancy should begin before conception, as fetal development begins from the third week after the last menstrual period. Being as fit and healthy as possible before conception maximizes chances of a healthy pregnancy, but not all poor obstetric outcomes can be avoided. Pre-pregnancy counselling by a specialist team is recommended where specific risks and diseases are identified. Scuba diving may result in fetal birth defects and fetal decompression disease and, therefore, is not recommended.


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Oligomenorrhoea Normal puberty is associated with an increase in insulin resistance cardiovascular disease ppt buy 30 mg procardia amex. Successful pregnancies have been reported following radiotherapy 2 umbilical arteries buy 30mg procardia visa, but there is risk of miscarriage arteries 10 generic procardia 30 mg otc, premature delivery, and intrauterine growth restriction. With high-dose cranial irradiation progressive compromise occurs, 60% having gonadotrophin deficiency 4yrs after treatment. Even with low-dose cranial irradiation the presence of regular periods does not equate with fertility. Further malignancy Up to 4% of childhood cancer survivors will develop a second p malignancy within 25yrs of the initial cancer. This is thought to be the carcinogenic (stochastic) effect of radiotherapy and certain alkylating agents. The process is complex and aspects of its initiation, control, and cessation are not fully understood. Common causes of amenorrhoea Physiological causes 1 Pregnancy must always be excluded. A maternal or sibling history of dysmenorrhoea is very common and the problem usually starts soon after menarche. Where first-line therapy has failed, further medical treatment may be used in very anaemic women, bleeding continuously, having their life disrupted, or who have cautions or contraindications to surgery. Endometrial ablation Destruction of the endometrium down to the basalis layer is effective for most women and should be offered to all for consideration. There is a small risk of continuing light menstruation if residual endometrial cells are left, and women will continue to require smear tests. Perimenopausal women may have increasing premenstrual symptoms as well as menopausal symptoms. Exercise Moderate regular aerobic exercise promoting cardiovascular work is beneficial (three controlled studies). Stress reduction Relaxation techniques, yoga, meditation, breathing techniques, and encouragement of healthier lifestyle may also help.

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