Martin Moser, MD

• Assistant Professor of Medicine
• Department of Cardiology and Angiology
• University of Freiburg
• Freiburg, Germany

The involvement is bilateral but if unilateral erectile dysfunction treatment by ayurveda buy 20mg cialis soft overnight delivery, it is more frequent on the right side garlic pills erectile dysfunction order cialis soft no prescription. Important features are: Acute aching pain over the loins erectile dysfunction hotline 40mg cialis soft free shipping, often radiating to the groin and costovertebral angle tenderness erectile dysfunction underwear generic cialis soft 40 mg without prescription, urgency icd 9 code erectile dysfunction neurogenic order cialis soft amex, frequency impotence blood circulation order cialis soft toronto, dysuria, hematuria. Investigations: Apart from the routine ones, serum level of creatinine, electrolytes and culture studies of urine and blood should be done. Repeat urine culture after 2 weeks of antimicrobial therapy and is repeated at each trimester of pregnancy. If the symptoms recur or the dip stick test for nitrate and leukocyte esterase is positive, urine culture is repeated. Twenty-five percent of these women are likely to develop acute pyelonephritis, usually in third trimester, if left untreated. The increased association of premature labor and growth retarded babies is probably related with the underlying chronic renal lesion. Treatment: the antimicrobial agents should be appropriate to the mother and the fetus. The causes are: (1) Preeclampsia and eclampsia (2) Urinary tract infection (3) Chronic renal disease: nephritis and nephrotic syndrome (4) Essential hypertension (5) Orthostatic -Due to increased lumbar lordosis there is increased pressure on the inferior vena cava by the uterus or the left renal vein is compressed by the aorta. In late pregnancy, the enlarged gravid uterus may compress the left renal vein when the patient is placed on supine position. Investigation: If the history (present and past) and clinical examination fail to find out the cause, the investigation protocols are designed to rule out infection of the urinary tract and renal parenchymal lesion. Orthostatic proteinuria in the absence of bacteriuria or hypertension is not significant. Those unrelated to pregnancy Those related to the pregnant state are: (1) Severe cystopyelitis (2) Rupture of bladder varicosities (3) Following rapid evacuation of urine in acute retention with a retroverted gravid uterus (4) lower segment scar rupture involving the bladder (5) Operative delivery following obstructed labor due to congestion. Those unrelated to pregnancy as urinary calculi, renal tuberculosis, renal neoplasm, papilloma bladder. Treatment consists of-(a) to increase the urinary output by adequate fluid intake and (b) to correct the pathology by medical or surgical treatment. The causes are divided into-(A) During early pregnancy - (1) Incarcerated retroverted gravid uterus (2) Impacted pelvic tumors. If simple measures fail, catheterization is to be done using a disposable catheter. Maternal Rubella infection is manifested by rash, malaise, fever, lymphadenopathy and polyarthritis. Risk of major anomalies when this infection occurs in first, second and third month is approximately 60%, 25% and 10%, respectively. The virus predominantly affects the fetus and is extremely teratogenic if contracted within the first trimester. There is increased chance of abortion, stillbirth and congenitally malformed baby. Infants born with congenital rubella shed the virus for many months and is a source of infection to others. Test for rubella specific antibody (IgM) should be done within 10 days of the exposure to know whether the patient is immune or not. Rubella specific IgG antibodies are present for life after natural infection or vaccination. If the patient is not immune, question of therapeutic Chapter 20 Medical and Surgical Illness Complicating Pregnancy 349 termination should be seriously considered. When given during the child-bearing period, pregnancy should be prevented within three months by contraceptive measure. However, if pregnancy occurs during the period, termination of pregnancy is not recommended. Non-immunized women coming in contact with measles may be protected by intramuscular injection of immune serum globulin (5 ml) within 6 days of exposure. Influenza strains are named according to their genus, species and H and N subtypes. There is no evidence of its teratogenic effect even if it is contracted in the first trimester. However, outbreak of Asian influenza showed increased incidence of congenital malformation (anencephaly) when the infection occurred in the first trimester. Oseltamivir (neuraminidase inhibitor), an antiviral drug, reduces the severity, secondary complications and death. The risk of congenital malformation is nearly absent when maternal infection occurs after 20 weeks. Oral acyclovir, valacyclovir is safe in pregnancy and reduce the duration of illness when given within 24 hours of the rash. It mainly affects the erythroid precursor cells resulting in anemia, thrombocytopenia, aplastic crises, congenital heart failure and hydrops. Fetal middle cerebral artery peak Doppler velocity can be studied to detect any significant fetal anemia before hydrops develop. Reactivation or recurrent infection occurs resulting in virus shedding with or without symptomatic lesions. The fetus becomes affected by virus shed from the cervix or lower genital tract during vaginal delivery. The baby may be affected in utero from the contaminated liquor following rupture of the membranes. Acyclovir 400 mg three times daily for five days is the drug of choice when virus culture is positive. Neonatal infection may be disseminated (fatal) or localized or it may be asymptomatic. It is manifested as chorioretinitis, microcephaly, mental retardation, seizures and deaths. Breastfeeding is allowed provided the mother avoids any contact between her lesions, her hands and the baby. Infected pregnant women present with acute febrile illness, headache, myalgia, facial flushing, retro-orbital pain, skin rashes (maculopapular) and rarely with hemorrhage. Triad of symptoms are: hemorrhagic manifestations, plasma leakage and platelet counts <100000/ mm3. Maintenance of intravascular volume, blood pressure and fluid replacement is to be done. Incidence: Incidence is difficult to work out but the fact remains that the disease is alarmingly increasing both in the developed and in developing countries. Once the virus is into the genome of the host, it produces multiple copies of itself, which will eventually cause host cell damage. Transplacental transmission occurs: 20% before 36 weeks, over 80% of transmissions occur around the time of labor and delivery. Vertical transmission is more in cases with preterm birth and with prolonged membrane rupture. Maternal anti-retroviral therapy reduces the risk of vertical transmission by 70% (see below). Male to female transmission is about double compared to female to male transmission. After a peak viral load, there is gradual fall until a steady state of virus concentration is reached. Clinical presentation: Initial presentation of an infected patient may be fever, malaise, headache, sore throat, lymphadenopathy and maculopapular rash. There may be associated constitutional symptoms like weight loss, lymphadenopathy or protracted diarrhea. If the count falls to less than 200 cells/mm3, the patient should receive prophylaxis against Pneumocystis carinii and other opportunistic infections. Triple chemotherapy is preferred as a first line defence and to be started any time between 14 weeks and 28 weeks and then continued throughout pregnancy, labor and postpartum period. Women with viral load < 400 copies/ml, neonatal infection was 1%, whereas infection rate was >30% when maternal viral load was >100,000 copies/ml. Elective cesarean delivery reduces the risk of vertical transmission by about 50%. Perioprative or peripartum broad spectrum antibiotics should be given as per hospital protocol. Invasive procedures that might result in break in the skin or mucous membrane of the infants (procedures like attachment of scalp electrode and determination of scalp blood pH) are contraindicated. Amniotomy and oxytocin augmentation for vaginal delivery should be avoided whenever possible. Mechanical suctioning devices should be used to remove secretions from the neonates airways. Blunt tipped needles should be used to avoid needle stick injury and washing on any blood contamination from the skin immediately. Health-care workers should be protected from contact with potentially infected body fluids. Post exposure prophylaxis with triple therapy for 4 weeks, reduces the risk of seroconversion by more than 80%. Disposable syringes and needles are used and they are deposited in the puncture proof containers. Neuropathy, myopathy, lactic acidosis, pancreatitis, hepatitis and mitochondrial toxicity have been observed. However, condom use should be continued regardless of the use of other method of contraception. The disease could be prevented predominantly by health education and by practice of safer sex. The woman needs ongoing care with a multidisciplinary team including social workers and counselors. The counselor must provide up to date knowledge which enables the patient to make an informed choice. Second trimester is the safest time for surgery as the risks of teratogenesis, miscarriage and preterm delivery are lowest. Imaging of abdominal organs is difficult in pregnancy due to the presence of gravid uterus. Management of pregnant woman with trauma should always be to stabilize the mother first, with evaluation of the fetus thereafter. Operation should be done preferably by a senior surgeon with an expert anesthetist. In majority of cases, taken all the precautions, the risk of adverse perinatal outcome is low. However, risk of surgery must be balanced against the complications of the underlying pathology that need surgery. Diagnosis is difficult in pregnancy due to (a) Nausea and vomiting common in normal pregnancy are also the common symptoms of appendicitis (b) leukocytosis is common in normal pregnancy (c) Appendix moves upwards and outwards as the uterus enlarges. Effect of appendicitis on pregnancy-may lead to miscarriage, preterm delivery, increased perinatal mortality and maternal mortality. Effect of pregnancy on appendicitis is adverse because of (a) late diagnosis (b) failure of localization due to displacement of the position and as such (c) peritonitis is more common, specially, in last trimester. The risks of maternal and fetal mortality from appendicitis in pregnancy is high specially when associated with perforations. Appendiceal mural thickening, periappendiceal fluid and a noncompressible tubal structure (6 mm or more) are suggestive. Once the diagnosis is suspected, it is essential to operate rather than to wait until generalized peritonitis has developed. Placental abruption is the common complication following minor as well as major abdominal trauma. Common types of penetrating trauma in pregnant women are due to road traffic accidents, gunshot or stab wounds. Maternal death rates in penetrating trauma is two-thirds lower than in the non-gravid women. Once the diagnosis is made, the treatment should be conservative rather than surgical. It is the second most common nongynecological condition that needs surgery during pregnancy. Deterioration of clinical condition despite medical therapy or recurrent billiary colic needs cholecystectomy regardless of trimester. Fetal risks and preterm labor are less as the uterine manipulation and the use of narcotics are less. Obstetric consultation is essential for preoperative and postoperative management. Risk of aspiration during anesthesia could be reduced using antacid, and H2 blocker beforehand. Patient should be in the left lateral decubitus with minimum reverse trendelenburg 5. Antithrombotic prophylaxis are: use of pneumatic compression devices (intraoperative as well as postoperative) and early postoperative ambulation.

The parathyroid glands consist essentially of columns of cells separated by sinusoids latest advances in erectile dysfunction treatment safe 40 mg cialis soft. Cells of the second type are called oxyphil or eosinophil cells as they contain granular structures that stain with eosin buy erectile dysfunction pills online uk generic cialis soft 20mg online. When there is a tendency for serum calcium levels to fall calcium is removed from stores in bone bringing serum levels back to normal erectile dysfunction tea discount cialis soft express. Simultaneously erectile dysfunction treatment operation purchase 40mg cialis soft with visa, the excretion of calcium by the kidney is decreased erectile dysfunction 17 cheap cialis soft express, and calcium absorption by the intestines is increased erectile dysfunction bph cheap cialis soft 20mg without prescription. Calcitonin secreted by the parafollicular cells of the thyroid gland has effects opposite to those of the parathyroid hormone. A decrease in serum calcium levels stimulates the secretion of parathyroid hormone, while an increase stimulates the secretion of calcitonin. The variations in position of parathyroid glands described above are of considerable importance to a surgeon trying to locate the glands. The parathyroid glands can be seen when the thyroid is imaged using radioactive iodine. The areas where radioactive materials are located can be recorded on a gamma camera. Excessive amounts of circulating parathormone can be present in tumours of the parathyroid gland (parathyroid adenoma). The condition may be spontaneous or may occur following accidental removal of parathyroid glands during thyroidectomy. The term carotid sinus is applied to a dilated segment of the common carotid body located at its bifurcation. Chapter 46 Endocrine Glands of the Head and Neck, Carotid Sinus and Carotid Body want to know more In the region of the dilatation, the tunica media in the arterial wall is thin, but the adventitia is thick. The main contribution to this plexus is by the carotid branch of the glossopharyngeal nerve. The afferent nerve terminals present over the carotid sinus are stimulated by alterations in blood pressure. These are small oval structures, present one on each side of the neck, at the bifurcation of the common carotid artery. The main function of the carotid bodies is that they act as chemoreceptors that monitor the oxygen and carbon dioxide levels in blood. In addition to this function the carotid bodies are also believed to have an endocrine function. The most conspicuous cells of the carotid body are called glomus cells (or type I cells). This term is used to describe small collections of neuroendocrine cells present in association with autonomic nerves. Structures similar to the carotid bodies, present in relation to the inferior aspect of the arch of the aorta are also included in paraganglia. For sake of convenience in revision the descriptions are grouped together in this chapter. Surface Marking of SoMe ViScera Parotid gland the parotid gland has been described on page 760. To mark the anterior border, begin at the upper border of the head of the mandible. Now carry the line downwards and backwards to reach a point just posteroinferior to the angle of the mandible. Draw a line upwards to reach the anterior border of the mastoid process, near its upper end. To mark the superior border join the upper ends of the posterior and anterior borders by a line that is convex downwards. This line corresponds to the lower part of the margin of the external acoustic meatus. It can be marked on the lobule of the ear, but it is more useful to mark it by lifting the lobule upwards. Draw a line running forwards from the lower border of the tragus to a point midway between the ala of the nose and the upper lip. The position of the parotid duct corresponds to the middle one-third of this line. Before marking the gland you must have an idea of its shape and of its division into the isthmus and the right and left lobes. To mark the isthmus of the gland, begin by feeling the lower border of the arch of the cricoid cartilage. Take one point half an inch below the border of the cricoid cartilage, and another point half inch lower down (Remember that one-inch is equal to 2. To mark the anterior border start at the lateral end of the upper border of the isthmus (marked above). Carry the line upwards and slightly backwards to reach the anterior border of the sternocleidomastoid muscle, at the level of the middle of the thyroid cartilage. Draw a line running downwards (with a slight backward convexity) to reach the clavicle. To complete the marking of the lobe, join the lower end of the posterior border to the lateral end of the lower border of the isthmus by a broad line convex downwards. To draw the upper margin of the gland, draw a line convex upwards, starting at the angle and reaching the middle of the base of the mandible. To mark the lower margin of the gland join the two ends of the upper margin (drawn as described above) by a line convex downwards. The curve should extend below to the level of the greater cornu of the hyoid bone. To mark it draw a small oval just in front of, and above, the angle of the mandible. We will consider the surface marking only of the frontal and maxillary sinuses (as these are large and lie near the surface). The lower end of the line should be just above the depression between the forehead and the upper end of the nose. To mark the lower border of the sinus draw a line starting at the lower end of the medial border, and passing laterally and slightly upwards to reach the upper margin of the orbit. The line should lie just above the medial one-third of the superior orbital margin. The third border (above and laterally) is drawn by joining the upper end of the medial border with the lateral end of the lower border. The left artery runs part of its course in the thorax where its surface marking has been studied in an earlier chapter. It lies over the anterior border of the sternocleidomastoid muscle at the level of the upper border of the thyroid cartilage. From this level draw a broad line running upwards and ending just behind the condyle of the mandible. The lower end of this artery corresponds to the termination of the common carotid artery. It lies over the anterior border of the sternocleidomastoid muscle at the level of the thyroid cartilage. The line should be slightly convex forwards in its lower half, and slightly convex backwards in its upper half. The left subclavian artery runs part of its course in the thorax where its surface marking has been described earlier. Passing laterally with an upward convexity to a point over the middle of the clavicle. We have seen that the artery runs part of its course in the neck, and passes through the submandibular region before entering the face. The facial artery enters the face where the anterior border of the masseter cuts the lower border of the mandible. The artery divides into frontal and parietal branches at the upper end of this line. Draw a line starting at the upper end of the main stem (see above) and running upwards with a forwards convexity (42. From here the frontal branch runs upwards and backwards to end approximately midway between the root of the nose and the external occipital protuberance. The parietal branch begins at the upper end of the main stem of the middle meningeal artery (see above). It runs backwards to a point about 6 cm above the external occipital protuberance. VeinS internal Jugular Vein the internal jugular vein has been described on page 854. The vein runs downwards across the sternocleidomastoid and ends deep to the clavicle immediately behind the sternocleidomastoid muscle. Its anterior end reaches the raised area between the right and left eyebrows (glabella). The line joining the two points is short because of foreshortening of the projection. The nerves considered are those than can be approached surgically from the surface (It is always useful to read the course of the nerve before trying to understand surface marking). The main stem of the mandibular nerve can be marked on the surface as a short vertical line just in front of the head of the mandible. It can be marked by a line that runs backwards from the main stem of the mandibular nerve, across the neck of the mandible. The nerve then turns upwards passing immediately in front of the tragus (preauricular point). To mark it draw a line continuous with the main stem of the mandibular nerve (see above). It is represented by a line that runs downwards and forwards to reach opposite the lower third molar tooth. It is useful only to mark the extracranial part of the nerve, before it divides into several branches. This foramen lies deep to the middle of the anterior border of the mastoid process (In the adult, the nerve lies at a depth of 2 cm, but the depth is much less in children). From here draw a horizontal line that runs forwards to end just behind the neck of the mandible. This nerve is marked by a line that runs downwards and forwards with a downward convexity. It can be represented by a straight line running down the entire length of the neck. From here draw a line downwards and backwards to reach a point midway between the mastoid process and the angle of the mandible. From this point carry the line further downwards and backwards to reach the middle of the posterior border of the sternocleidomastoid muscle. The nerve then runs across the posterior triangle to reach the anterior border of the trapezius about two inches above the clavicle. From here draw a line downwards and medially to reach the medial end of the clavicle. To mark this chain remember that it runs vertically immediately behind the carotid sheath. In contrast, the peripheral nervous system consists of the cranial nerves and the spinal nerves. The nervous system is made up, predominantly, of tissue that has the special property of being able to conduct impulses rapidly from one part of the body to another. The specialised cells that constitute the functional units of the nervous system are called neurons. Within the brain and spinal cord, neurons are supported by a special kind of connective tissue that is called neuroglia. Nervous tissue, composed of neurons and neuroglia, is richly supplied with blood, but lymph vessels are not present. Most neurons give off a number of short branching processes called dendrites and one longer process called an axon. In a dendrite, the nerve impulse travels towards the cell body whereas in an axon the impulse travels away from the cell body. Peripheral nerves are made up of aggregations of axons (and in some cases of dendrites). During its formation, each axon (and some dendrites) comes to be associated with certain cells that provide a sheath for it. The cells providing this sheath for axons lying outside the central nervous system are called Schwann cells. Axons lying within the central nervous system are provided a similar covering by a kind of neuroglial cell called an oligodendrocyte. Within the central nervous system, it always terminates by coming in intimate relationship with another neuron, the junction between the two neurons being called a synapse. Outside the central nervous system, the axon may end in relation to an effector organ. Neurons vary considerably in the size and shape of their cell bodies (somata) and in the length and manner of branching of their processes. The shape of the cell body is dependent on the number of processes arising from it. The most common type of neuron gives off several processes and the cell body is, therefore, multipolar. Another type of neuron has a single process and is therefore described as unipolar.

This is not to say that healthy uncomplicated cases should not get proper attention natural treatment erectile dysfunction exercise order cialis soft 20 mg on-line. But in general they need not be admitted to specialized centers and their care can be left to properly trained midwives and medical officers in health centers top rated erectile dysfunction pills cheap 40 mg cialis soft mastercard, or general practitioners erectile dysfunction treatment hypnosis buy cialis soft 40 mg on-line. It is necessary that all expectant mothers are covered by the obstetric service of a particular area erectile dysfunction more causes risk factors buy 40mg cialis soft overnight delivery. The service of trained community health workers and assistant nursecum-midwife of health centers should be utilized to provide the primary care and screening in rural areas and urban and semiurban pockets erectile dysfunction venous leak buy cheap cialis soft on-line. A simple checklist should be prepared for them to fill up; arrangement should be made for early examination of the high-risk cases by medical officers of health centers in the health center itself or in small community antenatal clinics situated in different rural area impotence by age purchase cialis soft canada, catering to a small group of population. The health centers of clinics should have periodic specialist cover from teaching or nonteaching hospitals, as well as district and subdivisional hospitals. The general practitioner or medical officer of health centers, in collaboration with the specialists will decide what type of cases (with a comparatively lower risk) can be managed at home or health centers. Cases with a significantly higher risk should be referred to specialized referral centers. Cases from rural areas may be kept at maternity waiting homes close to the referral centers. The organizational aspect may be summarized as follows: Strengthen Proper midwifery skills, community participation and referral (transport) system training of resident, nursing personnel and community health workers Arranging periodic seminars, refresher courses with participation of workers involved in the care of these cases Chapter 39 Special Topics in Obstetrics Concentration Community 719 of cases in specialized centers for management participation, proper utilization of health care manpower and financial resources where it is mostly needed Availability of perinatal laboratory for necessary investigations; availability of a good pediatric service for the neonates Lastly, improvement of literary rate, health awareness of the community and economic status. Cases having a previous unsuccessful pregnancy should be seen and investigated before another conception occurs. Investigations like hysterography, hysteroscopy, laparoscopy or transvaginal ultrasonography should be performed to rule out Mullerian abnormality. Complete investigations for hypertension, diabetes, kidney disease or thyroid disorders should be undertaken and proper treatment instituted in the nonpregnant state. Sexually transmitted diseases should be treated before embarking on another pregnancy. Serology for toxoplasma IgG, IgM and antiphospholipid antibodies should be done and corrected appropriately when found positive (see p. Folic acid (4 mg/day) therapy should be started in the prepregnant state and is continued throughout the pregnancy. Early in pregnancy after the initial clinical examination, routine and special laboratory investigations should be undertaken. Minimum medicines should be taken during pregnancy, particularly in the early months. Assessment of maternal and fetal well-being: this should be done at each antenatal visit according to the guidelines given in the appropriate chapter; maternal complications should be looked for and treated, if necessary. Those cases who go into labor spontaneously or after induction, need close monitoring during labor for the assessment of progress of labor or for any evidence of the fetal hypoxia. The condition of the fetus can be assessed by- Fetal heart rate monitoring: By stethoscope, fetoscope or Doppler-Continuous electronic monitoring (see p. In this chapter a short review of the selected areas will be made highlighting the immunological explanations. The mysterious mechanism of the immune system that prevents rejection of fetus remains unknown to the immunobiologists. Why the fetal allograft that receives half of its histocompatibility antigens from the father is not rejected Some complications in pregnancy are associated with underlying immunological etiology. When pathogens (viruses) replicate inside the cells and are inaccessible to antibodies, are destroyed by T cells. Women are able to respond to both humoral and cell mediated immunity against the paternal antigen. These trophoblast cells (placenta) form the interface between the fetus and the mother. Thus the placenta forms an efficient barrier against the transmission of immunocompetent cells between the fetus and the mother. The trophoblast covering the chorionic villi (villous trophoblasts) comes in contact with the maternal blood in the intervillous space and interacts with maternal systemic immune response. During pregnancy, maternal immune response is shifted (immunomodulation) from Th 1 (cell mediated) to Th 2 (humoral mediated) type. Th 2 type response is beneficial due to the production of anti-inflammatory cytokines. Immunomodulation results in improvement of woman with rheumatoid arthritis in pregnancy. Immunological mechanisms involved in pregnancy are not the same as that of organ transplantation. Immunological tolerance through complement and cytokines regulation is protective for pregnancy. Chapter 39 Special Topics in Obstetrics 721 Other postulations are- Maternal fetal cell trafficking and microchimerism: Maternal tolerance of fetus is due to bidirectional cell trafficking between the mother and fetus. The existence of two cell populations in a single person is known as microchimerism. The levels of complements and cytokines (proinflammatory factors) are often raised during pregnancy. Inhibition of such complements and cytokines by the placenta reduces the immune mediated pregnancy complications. Except for the fact that A1 antigen is strong, it has not been clearly known as to why the A1 fetuses mostly take the brunt. Fetal RhD positive red cells gaining entry into the circulation of Rh-negative mother take several weeks to immunize her. Under these circumstances, the mother will form anti RhD agglutinin which will pass again through the placental barrier into the fetus giving rise to agglutination or hemolysis of fetal erythrocytes which ultimately may lead to dangerous situations like hydrops fetalis, icterus gravis neonatorum or kernicterus. There is failure of extravillous trophoblasts invasion and spiral artery remodeling. Preeclampsia is associated with widespread systemic inflammation and endothelial dysfunction. The immune dysfunction in preeclampsia are as follows: There is decrease in regulatory T cells both in number and function. There is insufficient shift from Th-1 to Th-2 as opposed to normal pregnancy where Th-2 predominance is observed. Th-1 cells produce proinflammatory cytokines whereas Th-2 cells produce anti-inflammatory cytokines. Progesterone has an immunomodulatory role to induce a pregnancy protective shift from Th-1 cytokine response to more favorable Th-2 cytokine response. Myasthenia gravis also has some such relationship due to transplacental transfer of acetylcholine-blocking factor. Antibodies present in the female reproductive tract that binds the sperm surface antigens affect the motility of sperm and may cause infertility. Often these women are assessed clinically, based on specific abnormalities in physical examination of vital parameters, including laboratory values and imaging studies. Antenatal transfer rather than with newborn transfer is preferred except in a situation, where maternal transport is unsafe or impossible. Cardiopulmonary approach: the team members involve physicians, Heart disease in Postabortal pregnancy anesthetists, cardiologists, pulmonologists, Pregnancy Thromboembolism (Chorioamnionitis, intensivists, respiratory therapists, pharmacists pyelonephritis) and nurses. Obstetric critical care unit involves obstetricians, obstetric nurses and neonatologists. Base deficit mEq/L) 1 3 Level 3: Other intensive care units: For patients requiring long-term ventilator support. Use of pulmonary artery catheter is informative specially, in cases with severe preeclampsia, eclampsia, respiratory distress syndrome and amniotic fluid embolism. Pulmonary artery catheter values: Normally, pulmonary capillary wedge pressure (mm Hg) at term pregnancy is 7. Safe delivery of a woman needs consideration of period of gestation (fetal survival), place and mode of delivery (vaginal or cesarean). Effects of obstetric medications need to be carefully judged in terms of risks and benefits. Benefits of antenatal corticosteroids are established and it is to be given in the event of preterm delivery (< 34 weeks). However, fetal interest comes second and essential medications should not be withheld to the pregnant woman. Place of perimortem cesarean delivery: There is no such clear guideline regarding this issue. However, it is observed that cesarean delivery should be considered for both maternal or fetal benefits about 4 minutes after a pregnant woman has experienced total cardiopulmonary arrest in the third trimester. Pulmonary artery catheterization are of immense value in the management (see above) Critical care unit management involves multidisciplinary approach (see p. Necessary medications should not be withheld from a pregnant woman because of fetal concerns. However, attempts should be made to limit fetal exposure (drugs/radiation) as much as possible. Postoperative morbidity like fever, endometritis, wound infection, peritonitis, and also pelvic abscess can significantly be reduced. However an institution, where infection rate is high, should primarily improve the surgical and aseptic technique. Emergency cesarean section is associated with higher rate of infection than the elective procedure. Similarly cases with prolonged rupture of membranes and in prolonged labor are at higher risk of infection. Infective agents are mostly polymicrobial, including Gram-positive, Gram-negative aerobes and anaerobes. Ideally the antibiotic infusion should be timed so that a bactericidal serum level is reached by the time skin incision is made. It is recommended that prophylactic antibiotic should be administered within 60 minutes of the start of the cesarean delivery. Bacteriology pattern and antibiotic sensitivity need to be monitored regularly by the microbiology laboratory. Objective is to provide rest, risk assessment and treatment to avoid any complication. When such a patient is seen in the day care unit, repeated blood pressure measurement is done. Fetal well-being is assessed by clinical examination and also with cardiotocograph and ultrasonography for liqor volume and fetal weight. Chapter 40 Current Topics in Obstetrics 727 Similarly women with diminished fetal movements could be assessed in a day care unit. Advantages: (i) this acts as a safety net for assessment of obstetric complaints, (ii) Reduces inpatient overcrowding and workload specially in a busy hospital, (iii) Reduces the stress of the woman due to separation from the family, (iv) It reduces concomitant costs. This is due to great expectations of the society with progressive technological advancement. Medicolegal problems in obstetric practice are, therefore, rising both in the developed and in the developing world. Care and attention must be according to the established norms available at that time and place. When the doctor fails to exercise that duty properly, he is found to be negligent. The failure to perform the proper duty to patient care may be due to his incompetence or malpractice or mere negligence. The failure to provide a standard care may again be either by acts of omission or commission. Adverse outcomes of medical care are often due to: (i) System errors (inadequate staff, physician or operating room, etc. Once the act of substandard care due to system error, negligence, malpractice or incompetence is proved in the court of law, the plaintiff has to be compensated. Where conflicts arise, the doctor should seek help of and advice from other professional colleagues. Seniors must be available for consultation or direct involvement as and when asked for. Audit (clinical review) is an effective tool to indicate that change is essential. It is done by changing and strengthening many aspects of hospital practice and administration. Audit should not be confused with research which involves new experiments, investigations or treatment. Audit could be medical where scrutiny is done over the medical aspect of the work performed by the doctors. It could be clinical, where scrutiny is done over the work done by all health professionals including the doctors. Important aspect to organize an obstetric audit is motivation of all doctors, midwives and other health professionals. A target is set up to include maximum number (95%) of the patients in Chapter 40 the study. There must be an individual (Registrar/Lecturer) assigned for carrying out the audit. Finally this existing practice is critically analyzed, interpreted and then compared with the standard. A well-structured and efficient audit is based on scientific evidences with facts and figures.

These effects are mediated through connections between the reticular formation and autonomic centres in the brainstem and spinal cord erectile dysfunction what age does it start purchase 40 mg cialis soft amex, but the pathways concerned are not well defined erectile dysfunction nutritional treatment 40mg cialis soft. Neuroendocrine control Through its connections with the hypothalamus erectile dysfunction by country purchase cialis soft online now, the reticular formation influences activity of the adenohypophysis and of the neurohypophysis erectile dysfunction killing me purchase discount cialis soft. Alertness Through the ascending reticular activating system the reticular formation helps to maintain a state of alertness erectile dysfunction treatment massage purchase generic cialis soft. The thalamus (or dorsal thalamus) is a large mass of grey matter that lies immediately lateral to the third ventricle erectile dysfunction cholesterol lowering drugs cialis soft 20mg without prescription. It has two ends (or poles), anterior and posterior; and four surfaces, superior, inferior, medial and lateral. The medial surface forms the greater part of the lateral wall of the third ventricle, and is lined by ependyma. The medial surfaces of the two thalami are usually interconnected by a mass of grey matter called the interthalamic connexus. Inferiorly, the medial surface is separated from the hypothalamus by the hypothalamic sulcus. The lateral surface of the thalamus is related to the internal capsule that separates it from the lentiform nucleus (52. The superior (or dorsal) surface of the thalamus is related laterally to the caudate nucleus from which it is separated by a bundle of fibres called the stria terminalis, and by the thalamostriate vein. The thalamus and the caudate nucleus together form the floor of the central part of the lateral ventricle. The medial part of the superior surface of the thalamus is, however, separated from the ventricle by the fornix, and by a fold of pia mater called the tela choroidea (52. At the junction of the medial and superior surfaces of the thalamus the ependyma of the third ventricle is reflected from the lateral wall to the roof. Underlying it, there is a narrow bundle of fibres called the stria medullaris thalami (not to be confused with the stria medullares present in the floor of the fourth ventricle). The inferior surface of the thalamus is related to the hypothalamus anteriorly (49. Chapter 52 Diencephalon, Basal Ganglia, Olfactory Region and Limbic System 1097 52. Its superior surface is covered by a thin layer of white matter called the stratum zonale; and its lateral surface by a similar layer called the external medullary lamina. The grey matter of the thalamus is subdivided into three main parts by a Y-shaped sheet of white matter which is called the internal medullary lamina (52. Nuclei in the anterior part A number of nuclei can be distinguished, but we shall refer to them collectively as the anterior nucleus. The nuclei in the lateral part can be subdivided into a ventral group and a lateral group. The midline nuclei consist of scattered cells that lie between the medial part of the thalamus and the ependyma of the third ventricle. The reticular nucleus is made up of a thin layer of cells covering the lateral aspect of the thalamus. The cells of this nucleus are separated from the rest of the thalamus by the external medullary lamina. The medial and lateral geniculate bodies (described under metathalamus) are often included as part of the thalamus. Afferent impulses from a large number of subcortical centres converge on the thalamus (52. Exteroceptive and proprioceptive impulses ascend to it through the medial lemniscus, the spinothalamic tracts, and the trigeminothalamic tract. Visual and auditory impulses reach the lateral and medial geniculate bodies respectively. Sensations of taste are conveyed to the thalamus through solitario-thalamic fibres. Although the thalamus does not receive direct olfactory impulses they probably reach it through the amygdaloid complex. Visceral information is conveyed from the hypothalamus, and probably through the reticular formation. In addition to these afferents, the thalamus receives profuse connections from all parts of the cerebral cortex, the cerebellum, and the corpus striatum. Chapter 52 Diencephalon, Basal Ganglia, Olfactory Region and Limbic System 1099 52. The thalamus is, therefore, regarded as a great integrating centre where information from all these sources is brought together. This information is projected to almost the whole of the cerebral cortex through profuse thalamocortical projections. These thalamocortical fibres form large bundles that are described as thalamic radiations or as thalamic peduncles. These radiations are anterior (or frontal), superior (or dorsal), posterior (or caudal), and ventral. Efferent projections from the thalamus also reach the corpus striatum, the hypothalamus, and the reticular formation. Besides its integrating function, the thalamus is believed to have some degree of ability to perceive exteroceptive sensations, specially pain. The most important connections of the thalamus are those of the ventral posterior nucleus that receives the terminations of the major sensory pathways ascending from the spinal cord and brainstem. All these sensations are carried to the sensory areas of the cerebral cortex (areas 3,2,1) by fibres passing through the posterior limb of the internal capsule (superior thalamic radiation). Within the ventral posterior nucleus fibres from different parts of the body terminate in a definite sequence. The fibres from the lowest parts of the body end in the most lateral part of the nucleus. The medial lemniscus and spinothalamic tracts carrying sensations from the limbs and trunk end in the ventral posterolateral part; while the trigeminal fibres (from the head) end in the ventral posteromedial part, which also receives the fibres for taste. On the medial side, it forms the wall of the third ventricle below the level of the hypothalamic sulcus. Laterally, it is in contact with the internal capsule, and (in the posterior part) with the subthalamus. Posteriorly, the hypothalamus merges with the subthalamus, and through it with the tegmentum of the midbrain. Anteriorly, it extends up to the lamina terminalis, and merges with certain olfactory structures in the region of the anterior perforated substance. Inferiorly, the hypothalamus is related to structures in the floor of the third ventricle. For convenience of description, the hypothalamus may be subdivided, roughly, into a number of regions (52. Some authorities divide it (from medial to lateral side) into three zones that are as follows: a. The periventricular and intermediate zones are often described collectively as the medial zone. The tuberal (or infundibulo-tuberal) region includes the infundibulum, the tuber cinereum and the region above it. The preoptic region differs from the rest of the hypothalamus in being a derivative of the telencephalon. Hypothalamic Nuclei the entire hypothalamus contains scattered neurons within which some aggregations can be recognised. The preoptic nucleus extends through the periventricular, intermediate, and lateral zones of the preoptic part. The remaining nuclei of the hypothalamus lie either in the periventricular, intermediate, or lateral zones. The paraventricular nucleus the suprachiasmatic nucleus, lie in the supraoptic region the infundibular nucleus lies in the tuberal region the posterior nucleus extends into both the tuberal and mammillary regions. The anterior nucleus occupies the supraoptic region the dorsimedial nucleus the ventromedial nucleus lie in the tuberal part, which also contains small aggregations of cells that constitute the premammillary nuclei. The lateral zone contains a diffuse collection of cells that extends through the supraoptic, tuberal and mammillary regions. Small aggregations of neurons in the tuberal region constitute the lateral tuberal nuclei. Connections of the Hypothalamus the hypothalamus is concerned with visceral function and is, therefore, connected to other areas having a similar function. The hypothalamus receives visceral afferents (including those of taste) through the spinal cord and brainstem. Fibres from the tegmentum of the midbrain also reach the hypothalamus through the medial forebrain bundle. The hypothalamus receives afferents from several centres connected to olfactory pathways, and to the limbic system. Chapter 52 Diencephalon, Basal Ganglia, Olfactory Region and Limbic System want to know more Some fibres from the amygdaloid complex pass through the stria terminalis, and some through the medial forebrain bundle. The hypothalamus receives afferents from several parts of the cerebral cortex, and some from the cerebellum. The hypothalamus sends fibres to autonomic centres in the brainstem and spinal cord. The hippocampal formation the septal nuclei the amygdaloid complex the tegmentum of the midbrain. These fibres pass through the same bundles that convey afferent fibres from these centres. Fibres from the mammillary body pass through the mammillo-thalamic tract to reach the anterior nucleus of the thalamus. The supraoptic, paraventricular and infundibular nuclei exert an important influence on the hypophysis cerebri. Fibres arising from the supraoptic and paraventricular nuclei reach the pars posterior (neurohypophysis) through the supraoptico-hypophyseal and paraventriculo-hypophyseal tracts. The cells in these nuclei are peculiar in that they produce a secretion that travels along their axons and is released into the sinusoids of the neurohypophysis. The supraoptic nucleus is believed to mainly produce the antidiuretic hormone, and the paraventricular nucleus is believed to mainly produce oxytocin; though both nuclei produce both hormones. Axons of cells in the infundibular (arcuate) nucleus end in the median eminence and infundibulum. They travel through the tubero-hypophyseal tract that also receives fibres from several other hypothalamic nuclei. The axon terminals of the fibres in these tracts are closely related to capillaries in the region. The cells of the infundibular nucleus are believed to produce releasing factors that travel along their axons and are released into the capillaries. These capillaries carry these factors into the pars anterior of the hypophysis cerebri through the hypothalamohypophyseal portal system. In the pars anterior these factors are responsible for release of appropriate hormones. It may be noted, however, that in the case of some hormones their secretion is inhibited by such factors. Functions of the Hypothalamus the hypothalamus plays an important role in the control of many functions that are vital for the survival of an animal. In exercising such control the hypothalamus acts in close coordination with higher centres including the limbic system and the prefrontal cortex, and with autonomic centres in the brainstem and spinal cord. The main functions attributed to the hypothalamus are as follows: Regulation of Eating and Drinking Behaviour the hypothalamus is responsible for feelings of hunger and of satiety, and this determines whether the animal will accept or refuse food. Stimulation of the lateral zone stimulates hunger while stimulation of the medial zone produces satiety. Regulation of Sexual activity and Reproduction the hypothalamus controls sexual activity, both in the male and female. It also exerts an effect on gametogenesis, on ovarian and uterine cycles, and on the development of secondary sexual characters. These effects are produced by influencing the secretion of hormones by the hypophysis cerebri. Control of autonomic activity the hypothalamus exerts an important influence on the activity of the autonomic nervous system, and thus has considerable effect on cardiovascular, respiratory and alimentary functions. Sympathetic activity is said to be controlled, predominantly, by caudal parts of the hypothalamus; and parasympathetic activity by cranial parts, but there is considerable overlap between the regions concerned. Emotional Behaviour the hypothalamus has an important influence on emotions like fear, anger and pleasure. Stimulation of some areas of the hypothalamus produces sensations of pleasure, while stimulation of other regions produces pain or other unpleasant effects. Control of Endocrine activity the influence of the hypothalamus in the production of hormones by the pars anterior of the hypophysis cerebri, and the elaboration of oxytocin and the antidiuretic hormone by the hypothalamus itself, have been described above. Through control of the adenohypophysis the hypothalamus indirectly influences the thyroid gland, the adrenal cortex, and the gonads. Temperature Regulation the hypothalamus acts as a thermostat to control body temperature. When body temperature rises or falls, appropriate mechanisms are brought into play to bring the temperature back to normal. Biological Clock Several functions of the body show a cyclic variation in activity, over the twenty four hours of a day. Such cycles (called circadian rhythms) are believed to be controlled by the hypothalamus, which is said to function as a biological clock. These are small oval collections of grey matter situated below the posterior part of the thalamus, lateral to the colliculi of the midbrain (52. The medial geniculate body receives fibres of the lateral lemniscus either directly, or after relay in the inferior colliculus (52. The acoustic radiation passes through the sublentiform part of the internal capsule to reach the acoustic areas of the cerebral cortex.

Between the two plates lies the intervillous space containing the stem villi with their branches erectile dysfunction self treatment purchase cialis soft without prescription, the space being filled with maternal blood what causes erectile dysfunction in diabetes purchase discount cialis soft on line. At places erectile dysfunction at 20 order cialis soft 20 mg with visa, placental or decidual septa project from the basal plate into the intervillous space but fail to reach the chorionic plate erectile dysfunction from nerve damage purchase cialis soft amex. It is lined internally on all sides by the syncytiotrophoblast and is filled with slow flowing maternal blood erectile dysfunction treated by buy cialis soft once a day. With the progressive development - primary erectile dysfunction medications drugs cheap 20 mg cialis soft visa, secondary and tertiary villi are formed. Functional unit of the placenta is called a fetal cotyledon or placentome, which is derived from a major primary stem villus. Functional subunit is called a lobule, which is derived from a tertiary stem villi. Thus while some of the villi are anchoring the placenta to the decidua, the majority are free within the intervillous space and are called nutritive villi. Blood vessels within the branching villi do not anastomose with the neighboring one. In placenta at term, syncytiotrophoblast becomes relatively thin at places overlying the fetal capillaries and thicker at other areas containing extensive endoplasmic reticulum. The former is probably the site for transfer and the latter, the site for synthesis. Stroma contains dilated vessels along with all the constituents and few Hofbauer cells. Hofbauer cells are round cells that are capable of phagocytosis and can trap maternal antibodies crossing through the placenta (immune suppressive). A mature placenta has a volume of about 500 mL of blood; 350 mL being occupied in the villi system and 150 mL lying in the intervillous space. The villi depend on the maternal blood for their nutrition, thus it is possible for the chorionic villi to survive for a varying period even after the fetus is dead. Normally, there is cytotrophoblastic invasion into the spiral arteries initially up to the intradecidual portion within 12 weeks of pregnancy. There is a secondary invasion of trophoblast between 12 weeks and 16 weeks extending up to radial arteries within the myometrium. This concept of uteroplacental Pressure in the draining uterine vein 8 mm Hg circulation is based on the studies of Ramsey and coworkers (1963, 1966). Circulation in the intervillous space: the arterial blood enters the space under pressure. Mild stirring effect by the villi pulsation aided by uterine contraction help migration of the blood toward the basal plate and thence to the uterine veins. Sometimes syncytial sprouts are set free in the intravillous circulation and are carried through the maternal circulation to the lungs where they disappear by lysis. During uterine contraction, the veins are occluded but the arterial blood is forced into the intervillous space; while uterine relaxation facilit ates venous drainage. This is brought about by the fact that the spiral arteries are perpendicular and the veins are parallel to the uterine wall. Thus during contraction, larger volume of blood is available for exchange even though the rate of flow is decreased. The blood in the intervillous space is protected from clotting by some fibrinolytic enzyme activity of the trophoblast. They enter the chorionic plate underneath the amnion, each supplying one half of the placenta. The arteries break up into small branches which enter the stems of the chorionic villi. Each in turn divides into primary, secondary and tertiary vessels of the corresponding villi. The blood flows into the corresponding venous channels either through the terminal capillary networks or through the shunts. This countercurrent flow facilitates material exchange between the mother and fetus. The above two are separated by tissues Fetal blood flow 400 mL/min called placental membrane or barrier, consisting through the placenta of the following. In early pregnancy, it consists Pressure in the 60 mm Hg of (1) syncytiotrophoblast, (2) cytotrophoblast, umbilical artery (3) basement membrane, (4) stromal tissue, and Pressure in the 10 mm Hg (5) endothelium of the fetal capillary wall with umbilical vein its basement membrane. Sparse cytotrophoblast and distended fetal artery vein capillaries almost fill the villus. The thick "beta zones" of the terminal villi with the layers remaining thick in patches are for hormone synthesis. The aging process varies in degree and should be differentiated from the morbid process likely to affect the organ in some pathological states. These are called white infarcts which vary in size from few millimeters to a centimeter or more. Maternal properties Drug Molecular weight: Lower the molecular weight, more is the transfer Lipid solubility: Lipophilic substances diffuse readily concentration in the maternal blood Uterine blood flow Concentration gradient on either side of placental Ionization: Nonionized form crosses lipid membrane membranes freely C. Placental properties pH of blood: Lower pH favors ionization of many Lipid membrane of placenta enhances transfer drugs Total surface area of placental membrane Protein binding Functional integrity and thickness of placental barrier Spatial configuration (p. Immunoglobulin IgG is taken up by endocytosis from maternal circulation and is transferred to the fetus via exocytosis. Respiratory function: Although the fetal respiratory movements are observed as early as 11 weeks, there is no gaseous exchange. Intake of oxygen and output of carbon dioxide take place by simple diffusion across the fetal membrane. Partial pressure gradient is the driving force for exchange between the maternal and fetal circulations. Excretory function: Waste products from the fetus such as urea, uric acid, and creatinine are excreted in the maternal blood by simple diffusion. Nutritive function: the fetus obtains its nutrients from the maternal blood and when the diet is inadequate, then only depletion of maternal tissue storage occurs. Glucose which is the principal source of energy is transferred to the fetus by facilitated diffusion. Fetal glucose level is lower than that of the mother indicating rapid rate of fetal utilization of glucose. Lipids for fetal growth and development are transferred across the fetal membrane or synthesized in the fetus. Triglycerides and fatty acids are directly transported from the mother to the fetus in early pregnancy but probably are synthesized in the fetus later in pregnancy. Fetal proteins are synthesized from the transferred amino acids and the level is lower than in mother. Water and electrolytes such as sodium, potassium and chloride cross through the fetal membrane by simple diffusion, whereas calcium, phosphorus and iron cross by active transport (active transporter proteins) against a concentration gradient, since their levels are higher in fetal than in maternal blood. Water soluble vitamins are transferred by active transport, but the fat soluble vitamins are transferred slowly so that the latter remains at a low level in fetal blood. Chapter 3 the Placenta and Fetal Membranes 41 Hormones - Insulin, steroids from the adrenals, thyroid, chorionic gonadotrophin or placental lactogen cross the placenta at a very slow rate, so that their concentration in fetal plasma are appreciably lower than in maternal plasma. In general, substances of high molecular weight of more than 500 daltons are held up, but there are exceptions. Antibody and antigens in immunological quantities can traverse across the placental barrier in both directions. Maternal infections during pregnancy by virus (rubella, chickenpox, measles, mumps, poliomyelitis), bacteria (Treponema pallidum, Tubercle bacillus) or protozoa (Toxoplasma gondii, malaria parasites) may be transmitted to the fetus across the so-called placental barrier and affect the fetus in utero. Similarly, almost any drug used in pregnancy can cross the placental barrier and may have deleterious effect on the fetus. There is a shift of maternal response from cell-mediated (T helper 1) to humoral (T helper 2) immunity, which may be beneficial to pregnancy (see p. The cytokines thus derived, will regulate the invasion of extravillous trophoblast cells into the spiral arteries. The spiral arteries are thus converted to low resistance, high conductance uteroplacental arteries. The immunological response of implantation and that of organ transplantation are different and not comparable. Internally, it is attached to the amnion by loose areolar tissue and remnant of primitive mesenchyme. Externally, it is covered by vestiges of trophoblastic layer and the decidual cells of the fused decidua capsularis and parietalis which can be distinguished 42 Textbook of Obstetrics microscopically. Therefore human placenta is a discoid, deciduate, labyrinthine and hemochorial type (p. The outer surface consists of a layer of connective tissue and is apposed to the similar tissue on the inner aspect of the chorion from which it can be peeled off. The amnion can also be peeled off from the fetal surface of the placenta except at the insertion of the umbilical cord. Functions: (1) Contribute to the formation of liquor amnii; (2) Intact membranes prevent ascending uterine infection; (3) Facilitate dilatation of the cervix during labor; (4) Has got enzymatic activities for steroid hormonal metabolism; (5) Rich source of glycerophospholipids containing arachidonic acid - precursor of prostaglandin E2 and F2. Fluid accumulates slowly at first, but ultimately the fluid-filled cavity becomes large enough to obliterate the chorionic cavity; the amnion and the chorion come in loose contact by their mesenchymal layers. Production Transudation Removal of maternal serum across the placental Fetus swallows membranes every day. Chapter 3 the Placenta and Fetal Membranes 43 Initially, the cavity is located on the dorsal surface of the embryonic disk. Thus, the liquor amnii surrounds the fetus everywhere except at its attachment with the body stalk. The amnion is firmly attached to the umbilical cord up to its point of insertion to the placenta, but everywhere it can be separated from the underlying chorion. The presence of lanugo and epithelial scales in the meconium shows that the fluid is swallowed by the fetus and some of it passes from the gut into the fetal plasma (vide scheme). As the pregnancy continues post term, further reduction occurs to the extent of about 200 mL at 43 weeks. Color: In early pregnancy it is colorless, but near term it becomes pale straw colored due to the presence of exfoliated lanugo and epidermal cells from the fetal skin. Abnormal color: Deviation of the normal color of the liquor has got clinical significance. Meconium stained (green) is suggestive of fetal distress in presentations other than the breech or transverse. Depending upon the degree and duration of the distress, it may be thin or thick or pea soup (thick with flakes). But in late pregnancy, the composition is very much altered mainly due to contamination of fetal urinary metabolites. As pregnancy advances, there may be slight fall in the sodium and chloride concentration probably due to dilution by hypotonic fetal urine, whereas the potassium concentration remains unaltered. During pregnancy: (1) It acts as a shock absorber, protecting the fetus from possible extraneous injury; (2) Maintains an even temperature; (3) the fluid distends the amniotic sac and thereby allows for growth and free movement of the fetus and prevents adhesion between the fetal parts and amniotic sac; (4) Its nutritive value is negligible because of small amount of protein and salt content; however, water supply to the fetus is quite adequate. During labor: (1) the amnion and chorion are combined to form a hydrostatic wedge which helps in dilatation of the cervix; (2) During uterine contraction, it prevents marked interference with the placental circulation so long as the. Maternal abdomen is divided into quadrants taking the umbilicus, symphysis pubis and the fundus as the reference points. It is measured to diagnose the clinical condition of polyhydramnios or oligohydramnios respectively; (4) Rupture of the membranes with drainage of liquor is a helpful method in induction of labor (p. Initially, it is attached to the caudal end of the embryonic disk, but as a result of cephalocaudal folding of the embryo and simultaneous enlargement of the amniotic cavity the amnioectodermal junction converges on the ventral aspect of the fetus. As the amniotic cavity enlarges out of proportion to the embryo and becomes distended with fluid, the embryo is carried more and more into the amniotic cavity with simultaneous elongation of the connective stalk, the future umbilical cord. Covering epithelium: It is lined by a single layer of amniotic epithelium but shows stratification like that of fetal epidermis at term. It is rich in mucopolysaccharides and has got protective function to the umbilical vessels. Of the two umbilical veins, the right one disappears by the 4th month, leaving behind one vein which carries oxygenated blood from the placenta to the fetus. Allantois: A blind tubular structure may be occasionally present near the fetal end which is continuous inside the fetus with its urachus and bladder.

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