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Before delivery: There are signs of bruising, prolonged bleeding at the injection sites (venopuncture or intramuscular), gum bleeding or hemorrhage from the gastrointestinal tract and hypotension. 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. Laterally-The double fold of peritoneum of the broad ligament are attached between which the uterine artery ascends up. The law is clear that the fetus in utero has no legal rights up until the moment of birth. The indications are: (1) Neglected shoulder presentation with dead fetus; the neck is not easily accessible and (2) fetal malformations, such as fetal ascites or hugely distended bladder or monsters. Regeneration of the epithelium is completed by 10th day and the entire endometrium is restored by the day 16, except at the placental site where it takes about 6 weeks. Shortterm delay of 48 hours allows the use of corticosteroids that can reduce the perinatal mortality and serious morbidity significantly. Rupture of vasa previa, marginal sinus hemorrhage, circumvallate placenta, marked decidual reaction on endocervix or excessive show may be a possible cause of such bleeding. Optimum time of delivery for a growth restricted fetus may be between 34 weeks and 37 weeks depending upon the presence of any additional risk factor(s). The abdominal cavity and the abdominal wall are to be well packed to prevent contamination by the products of conception (to minimize scar endometriosis). Expert obstetric anesthetist is needed when the delivery is conducted under general anesthesia. This concentration gradient is maintained because an S1P-degrading enzyme, S1P lyase, is present in most tissues, so the lipid is catabolized in tissues more than in the lymph and blood. This results in higher local concentration of integrins at the sites of interaction with endothelial cells, where the chemokines are displayed, leading to increased overall strength (or avidity) of integrinmediated leukocyte binding to the endothelium. During this step, an assistant is asked to steady the head per abdomen in a manner of first pelvic grip. Forceps versus craniotomy in a dead fetus: If the delivery of the uncompressed head can be accomplished without much force with consequent injuries to the mother, forceps delivery is preferred. Vaginal examination for the diagnosis of placenta previa should not be done as it provokes severe hemorrhage (p. Some develop abundant cytoplasm and are called epithelioid cells because of their resemblance to epithelial cells of the skin. If Urobilinogen, Glucose, Bilirubin, there is change in color of the test end, the test is positive. Bladder changes: As a result of retention of urine, the bladder gets distended and becomes an abdominal organ reaching even upto the umbilicus. Partial mole Fetus may be viable, with signs of early growth restriction or structural abnormalities. Effects of pregnancy on renal disease: It depends on the severity of renal disease. If the baby is dead, perforation of the head is better than watchful expectancy, hoping for full dilatation of the cervix. In concealed variety-The following complications may occur either singly or in combination. Apart from some small aggregations of neurons, the grey matter of the region consists of the subthalamic nucleus and the zona incerta. Complications: Retropubic pain, osteitis pubis, stress urinary incontinence and rarely vesicovaginal fistula. To prevent preterm delivery, routine use of betamimetics or cerclage operation has got no significant benefit. But death of a fetus weighing less than 500 g (before 22 weeks) has got a distinct etiology and is usually termed as abortion. Medicolegal problems in obstetric practice are, therefore, rising both in the developed and in the developing world. Firstly, the axon arising from an interneuron may divide into a number of branches and may synapse with a number of different efferent neurons.

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Normally, mature mast cells are not found in the circulation but are present in tissues, usually adjacent to small blood vessels and nerves. Umbilical cord care: It is kept exposed to air and allowed to dry to promote early detachment. 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. Successful outcome depends on: (1) Degree of pelvic contraction; (2) Shape of the pelvis-flat pelvis is better than android or generally contracted pelvis; (3) Favorable vertex presentation-anterior parietal presentation with less parietal obliquity is favorable; (4) Intact membranes till full dilatation of cervix; (5) Effective uterine contractions and (6) Emotional stability of the woman. If there is any discomfort, such as after pain or painful piles or engorged breasts, they should be dealt with adequate analgesics (Ibuprofen). Sperm capacitation and acrosome reaction: Capacitation is the physiochemical change in the sperm by which it becomes hypermotile and is able to bind and fertilize a secondary oocyte. Ala of both the sides are absent and the sacrum is fused with the innominate bones. The deaths are due to rupture of the uterus, shock and sepsis with metabolic changes. Patient is asked to report after she misses her period to confirm and to locate the new pregnancy. During neonatal period, there may be direct contamination from other sites of infection or by chemical. Although they are normally not present in tissues, basophils may be recruited to some inflammatory sites. The most medial fibres (from the legs) come to lie most anteriorly in the medial lemniscus. Unlike persistent occipitoposterior, where occasional face-to-pubis delivery occurs, there is no possibility of spontaneous delivery in persistent mentoposterior. Hypoglycemia (blood glucose < 40 mg/dL) is observed in about 15% of infants due to lack of glycogen stores in the liver. The pacemaker of the uterine contractions is situated in the region of the tubal ostia from where waves of contractions spread downward. Antenatal: (1) To counsel the mother regarding the advantages of nursing her baby with breast milk, (2) To take care of any breast abnormality especially a retracted nipple and to maintain adequate breast hygiene especially in the last 2 months of pregnancy. Phagocytic vesicles fuse with lysosomes, where the ingested particles are destroyed. Malpresentation and malposition are associated with poor adaptation of the presenting part to the cervix. If glucose tolerance test is done, glucose leaks out in the urine even though the blood sugar level is well below 180 mg/100 ml (normal renal threshold). Shock proteinuria is probably due to renal anoxia which usually disappears 2 days after delivery, whereas proteinuria due to preeclampsia tends to last longer. Ambulation can reduce the duration of labor, need of analgesia and improve maternal comfort. They travel through the tubero-hypophyseal tract that also receives fibres from several other hypothalamic nuclei. Placenta marginata-A thin fibrous ring is present at the margin of the chorionic plate where the fetal vessels appear to terminate. Prophylactic low forceps or vacuum delivery may be done to shorten the duration of second stage.

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This countercurrent flow facilitates material exchange between the mother and fetus. Risks of antenatal corticosteroid use: (a) Premature rupture of the membranes especially with evidence of infection as the infection may flare-up; (b) Insulin-dependent diabetes mellitus where patients need insulin dose readjustment; (c) Transient reduction of fetal breathing and body movements. As a result of fetal anoxemia, there is damage to the liver leading to hypoproteinemia which is responsible for generalized edema (hydrops fetalis). In this section, we will describe the major properties of type I interferons and the antiviral actions of these cytokines. Knockout mice lacking the receptor for type I interferons are susceptible to viral infections. Muscular contraction enhances separation and facilitates its expulsion through the abdominal ostium. In the cavity: the causes of arrest of the head in the cavity are-(1) deflexed head and (2) contracted pelvis. Referral to secondary care may also be delayed if there is not an adequately high index of suspicion. Oxytocin (efferent arc via blood) is liberated from the posterior pituitary, produces contraction of the myoepithelial cells of the alveoli and the ducts containing the milk. This is brought about by the fact that the spiral arteries are perpendicular and the veins are parallel to the uterine wall. It is done in selected cases only when there is continued and excessive vaginal bleeding or maternal hypotension inspite of well-contracted uterus. Doppler ultrasound and cardiotocography are also informative and are noninvasive methods (p. Of these, ~2% are in the blood, ~4% in the skin, ~10% in the bone marrow, ~15% in the mucosal lymphoid tissues of the gastrointestinal and respiratory tracts, and ~65% in lymphoid organs (mainly the spleen and lymph nodes). The recognition of antigens by antibodies involves noncovalent, reversible binding. Different subsets of effector T cells exist, each with distinct functions, and these subsets have different although often overlapping patterns of migration. In case of any doubt to grade of 3rd degree tear, it is advisable to classify to the higher degree rather than lower degree. Liberal use of local antiseptics, aseptic measures during perineal wound dressing, use of clean bed linen and clothings are positive steps. The hemorrhage, so occurring, produces hematoma which may remain stationary or increase in size. It usually manifests for the first time beyond the 20th week and is characterized by the appearance of hypertension to the extent of 140/90 mm Hg or more and proteinuria with or without pathological edema. In any case, laparotomy is indicated by its own merit even though it may be proved otherwise. The details of lymphocyte activation and differentiation, as well as the functions of each of these populations, will be addressed later in this book. Other causes are: Nodular thyroid disease, sub-acute thyroiditis, hyperemesis gravidarum and trophoblastic disease. Risk of major anomalies when this infection occurs in first, second and third month is approximately 60%, 25% and 10%, respectively. This part of the parahippocampal gyrus forms a hook-like structure called the uncus. It begins in the amygdaloid complex and runs backwards in the roof of the inferior horn. A smaller Kd indicates a stronger or higher affinity interaction because a lower concentration of antigen and of antibody is required for complex formation. Thus, fibres to and from the anterior part of the frontal lobe pass through the anterior limb of the internal capsule.

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This also includes the correct principle of lifting and working positions during day-to-day activities. The collected blood is prevented from coming out of the cervix by the presenting part which presses on the lower segment. Imaging studies: Chest X-ray, renal ultrasound are needed depending upon the presentation. Having crossed the middle line, the corticospinal fibres turn downwards to enter the lateral white column of the spinal cord. Abnormal neurologic signs are: lethargy, poor feeding, vomiting, hypotonia and seizures. These are surrounded by flat cells and are called primordial follicles and are present in the cortex of the ovary. Self-assessment: (i) What antiseptic solutions are commonly used to clean the vulva and vagina prior to and following delivery It is to be introduced with the blades closed, to open up inside the uterine cavity, to grasp the products and to take out the instrument with a slight rotatory movement. This causes mechanical stretching of the lower segment and opening up (dilatation) of the cervical canal. Head and neck should be grasped and taken posteriorly while suprapubic pressure is applied by an assistant slightly toward the side of fetal chest. Till then, periodic examination is essential to note its lie, presentation, position and attitude. Memory cells appear to be heterogeneous, and there are subsets that differ especially with respect to their location and migratory properties. Microscopically, villi show edema and excessive syncytial knots, numerous cytotrophoblasts and thickened basement membrane. Viscosity of the lung fluid is a major factor for normal neonatal lung expansion and aeration. The cervix, as a result, is deviated to the left side (levorotation) bringing it closer to the ureter. In obstructed labor, the lower segment is very much stretched and thinned out and ultimately gives way (ruptures) especially in multiparae (see p. The gracile and cuneate fasciculi are much smaller than at lower levels as the fibres of these tracts progressively terminate in the gracile and cuneate nuclei. Autopsy and chromosome studies are done for fetuses with anomalies and dysmorphic features. Adequate treatment should be instituted to eradicate hookworm infestation, dysentery, malaria, bleeding piles, and urinary tract infection. They complain of weakness, shortness of breath, cough, nocturnal dyspnea and palpitation. Oxytocin may be required to reduce the risk of haemorrhage, but its use is associated with a theoretical risk of tissue dissemination leading to metastatic disease to the lungs or brain and should be avoided until the uterus is evacuated if possible. A 20 mL syringe, one 15 cm (6") 22 gauge spinal needle and about 20 mL of 1% lignocaine hydrochloride are required. Lactic acid and anoxia cause relaxation of the precapillary sphincters but not the postcapillary sphincters. There is reflex uterine vasoconstriction following uterine incision and manipulation. The anterior end of the parahippocampal gyrus is cut off from the curved temporal pole of the hemisphere by a curved rhinal sulcus. Incision on the abdomen: the surgeon may choose either a vertical or a transverse skin incision. The facial artery enters the face where the anterior border of the masseter cuts the lower border of the mandible. These are all suggestive of urethral obstruction, underactive detrusor muscle, or loss of coordination between detrusor construction and urethral relaxation. Another common feature of these cells is their involvement in immune responses that protect against helminths and reactions that cause allergic diseases.

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We will discuss the mechanisms and functional significance of isotype switching in Chapter 12. Severity of fetal affection is best assessed by fetal hemoglobin and hematocrit levels as determined by cordocentesis. The activities of all glycolytic enzymes in fetal erythrocytes except phosphofructokinase and 6-phosphogluconate dehydrogenase are higher than those of adults or term or premature infants. After a lapse of few days, the hemoglobin concentration is expected to rise at the rate of about 0. When enlarged (because of chronic infection) the pharyngeal tonsil is referred to as adenoids. Different cytokines have similar or overlapping actions, or are functionally unique. Breastfeeding jaundice is due to decreased intake of milk that leads to increased enterohepatic circulation. Naive B and T cells are mature lymphocytes that have not been previously stimulated by antigen. Infusion of polymolecular gelatin (hemaccel or gelofusion) as plasma expander avoiding dextran. The bladder walls get traumatized, which may lead to blood stained urine, a common finding in obstructed labor. Congestion, hemorrhage and ulceration are responsible for hematemesis (d) Lungs-Congestion or atelectasis leads to tachypnea or dyspnea, progressive hypoxemia and reduced pulmonary compliance. Early abortion: Dilatation and evacuation under analgesia or general anesthesia is to be done. 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. Common types of penetrating trauma in pregnant women are due to road traffic accidents, gunshot or stab wounds. Principle: the procedure reinforces the weak cervix by a nonabsorbable tape, placed around the cervix at the level of internal os. Intense signal lesions on T2 weighted images are Hematological changes: Blood volume - the extent of seen (From T. In affluent societies and in the developed countries, the incidence of the former is less than 10%. The cytokines indicated in bold are discussed in Chapter 10, in the context of T cell responses. Sickle cell disease is inherited structural abnormality involving primarily the chain of HbA. Category 4: Delivery is planned to suit the woman, family members and the hospital staff. Their axons (alpha efferents) leave the spinal cord through the ventral nerve roots of spinal nerves and innervate striated muscle. Feeling of hard skull bones either through the cervix or through the fornix usually suggests maturity. Cardiovascular disease Myocardial infarction and stroke are the primary clinical endpoints. Secondary lymphoid organs: responding to genetic and environmental cues in ontogeny and the immune response. This syndrome is manifested by nausea, vomiting, epigastric or right upper quadrant pain, along with biochemical, and hematological changes. If the head is floating, it is of 32 weeks pregnancy and if the head is engaged, it is of 40 weeks pregnancy. Impulses received from all these centres can spread to all centres within the limbic system through numerous interconnections, most of which are reciprocal. The most important form of thyroiditis is caused by an autoimmune process (autoimmune or lymphatic thyroiditis).

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Rugae partially reappear at 3rd week but never to the same degree as in prepregnant state. The disease could be prevented predominantly by health education and by practice of safer sex. Thus, it can only supplement the clinical assessment of pelvis but cannot replace the clinical examination. Hemodialysis (Artificial kidney): the principle of the artificial kidney is that of dialysis across a semipermeable (cellulose based) membrane which allows the crystalloids to diffuse down their concentration gradient but not the colloids. Phototherapy is contraindicated in infants with direct hyperbilirubinemia caused by liver disease or obstructive jaundice. Careful serial clinical assessment is needed to ensure adequate cervicometric progress of labor. Some features of a transverse section at this level have been introduced on page 1045 (49. Consent for operations the law does not specify who can take the consent for an operation, but the person obtaining consent should, at the very least, be familiar with the procedure and be able to explain it in detail. The reticular nucleus is made up of a thin layer of cells covering the lateral aspect of the thalamus. During introduction of the right blade, the traction-rod must be held forwards otherwise it will prevent locking of the blades. This is called fertilization or ovulatory age and is widely used by the embryologist. In contrast, the secreted forms of IgM and IgA form multimeric complexes in which two or more of the four-chain core antibody structural units are covalently joined. The four quadrant technique consists of measuring the vertical diameter of the largest pockets of the fluid found in each of the four quadrant of the uterus. Some fibres of the trunk and of the splenium, of the corpus callosum form a flattened band called the tapetum. Fetal factors: Marked deflection of the fetal head, too often favors posterior position of the vertex. This may be due to the disease itself with a genetic predisposition, or due to drug metabolism and de cient folate level. In acute types, the patient has acute pain abdomen with fainting attacks and may collapse. Infuse rapidly 2 liters of normal saline (crystalloids) or plasma substitutes like Haemaccel (colloids), an urea-linked gelatin, to reexpand the vascular bed. The medial surface of the palatine tonsil is covered by mucous membrane which is continuous with that of the palatoglossal folds; and below with the mucous membrane on the tongue. Acrosome sperm penetrate the zona pellucida reaches the perivitelline space fuses with the oocyte plasma membrane. These effects are produced by influencing the secretion of hormones by the hypophysis cerebri. The primitive germ cells take their origin from the yolk sac at about the end of 3rd week and their migration to the developing gonadal ridge is completed round about the end of 4th week. The wide occiput can comfortably be placed in the wider posterior segment of the pelvis. Bilateral ligation (not division) can avoid hysterectomy in about 50% of the cases. Maternal malnutrition, metabolic and endocrinal disorders like uncontrolled diabetes, epilepsy are related with increased incidence of fetal malformations. Basic facts underlying the clinical causes of maternal deaths are: Low social status of girls and women (gender inequality) is considered a fundamental determinant of maternal mortality. Detection of fetal red cells in the maternal blood (in case of Rh isoimmunization) Modified Kleihauer-Betke acid elution test. But when a fetal or neonatal death occurs, special attention must be given to the grieving patient and her family.

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The innate immune response is activated by recognition of a relatively limited set of molecular structures that are either products of microbes or are expressed by injured or dead host cells. ComPosiTion of the ColosTrum: It is deep yellow serous fluid, alkaline in reaction. The net effect of this disparity is inadequate exchange of oxygen and carbon dioxide between the intraand extravascular compartments. Normally, combined effects of estrogen and progesterone result in marked thickening of the intermediate layer with practically no superficial layer. Finally, the leukocytes move through cell junctions between endothelial cells into the tissues. Other congenital heart lesions Coarctation of aorta: the maternal risks are hypertension, aortic dissection, bacterial endocarditis and cerebral hemorrhage due to ruptured intracranial aneurysms. Ideal contraceptive methods should be highly (100%) effective, acceptive, safe, reversible, cheap, having non-contraceptive benefits, simple to use and requiring minimal motivation, maintenance and supervision. The dorsal part is bounded laterally by the inferior cerebellar peduncle in the lower part of the pons, and by the superior cerebellar peduncle in the upper part. A fold of mucous membrane starting at the tubal elevation passes down the pharyngeal wall. Factors contributing to the incident should be identified and an analysis report submitted. Associated complications that are likely to produce placental insufficiency-Ideally, pregnancy should not be allowed to go past the expected date. An attempt has been made to recognise discrete collections of neurons (or nuclei) in various regions of the spinal grey matter. Other Functions of Activated Macrophages In addition to killing phagocytosed microbes, macrophages serve many other functions in defense against infections. The risks include hemorrhage, shock, infection and rarely inversion of the uterus. 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. Follow-up: Follow-up of newborns should be organized depending upon the risks of feeding problems, infections, hyperbilirubinemia or other issues. The milk ejection reflex is inhibited by factors such as pain, anxiety, breast engorgement or adverse psychic condition (depression). Textbook of female urology and urogynaecology, published by Taylor and Francis, London. Steroidal contraceptives are better to be avoided due to hepatic microsomal enzyme induction (see p. Types of breech presentation are: complete, frank, footling and knee presentation. Protection against health disorders - (7) Pelvic inflammatory disease (thick cervical mucus); (8) Ectopic pregnancy; (9) Endometriosis; (10) Fibroid uterus; (11) Hirsutism and acne; (12) Functional ovarian cysts; (13) Benign breast disease; (14) Osteopenia and postmenopausal osteoporotic fractures; (15) Autoimmune disorders of thyroid; (16) Rheumatoid arthritis. Oxytocin acts on myometrial receptors and activates phospholipase C, which increases intracellular calcium level. In a woman who is having periods, a cyst of <5cm should not cause concern (or referral), unless there are other suspicious features or she is symptomatic. The upper trace shows intravesical pressure (Pves) and the middle trace shows pressure within the abdomen (Pabd), both measured against time. The effector functions of antibodies are initiated only by Ig molecules that have bound antigens and not by free Ig. The features of scar rupture are not as dramatic as those following obstructed labor (vide infra) and hence called "silent rupture". Understanding the sequence of sexual events and the interplay of physical factors (pain, lubrication, environment) helps to deal with the root cause. The cephalic presentation, being the absolute majority amongst the longitudinal lie, can be explained by: (1) Gravitation-the head being heavier comes down to the bottom. 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. Anticoagulation may need to be continued for 6 weeks to 6 months depending upon the case. Fetal anemia is corrected when the transfused erythrocytes are taken up by the sub-diaphragmatic lymphatics.

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Because microbes lack these regulatory proteins, the spontaneous activation can be amplified on microbial surfaces. A 7-day course of parenteral (first 48 hours) and oral antibiotic therapy is given. Recall that these cells contain abundant cytoplasmic granules filled with various inflammatory mediators that are released when the cells are activated, either by microbial products or by a special antibody-dependent mechanism. Fetal growth restriction and prolonged rupture of membranes also accentuates surfactant synthesis. Perforation caused by bigger size dilator or ovum or ring forceps or suction cannula: Diagnostic laparoscopy is helpful to assess the size and site of perforation and the amount of hemorrhage. It is more common in multiparae (5 times more than primigravidae) and in multiple pregnancy (eightfold increase than singleton pregnancy). Symptoms: the classic triad of symptoms of disturbed tubal pregnancy are: abdominal. It may either be due to the primary anatomic defect of the cervix or due to trauma or may be due to the complex pathology of infection or inflammation of decidua/membranes leading to uterine contractions and cervical ripening. As a result of suitable antenatal preparation, majority of women have labor that is easy and painless. New paternity Thrombophilias [antiphospholipid syndrome, protein C, S deficiency, Factor V Leiden (p. In (A) an Ig molecule is depicted binding to two widely spaced determinants on a cell surface, and in (B) the same antibody is binding to two determinants that are close together. Iron freed from transferrin is incorporated into hemoglobin (75%) and myoglobin or stored as ferritin or hemosiderin. Fourth stage: It is the stage of observation for at least 1 hour after expulsion of the afterbirths. The patients, however, have got persistent unilateral uneasiness in about one-third of cases before the acute symptoms appear. If repair is done prior to that, disruption of the wound is inevitable, if subsequent manual removal or exploration of the genital tract is needed. Diabetic retinopathy (Class R) is characterized by the proliferative retinopathy having neovascularization and microaneurysms. It can be iatrogenically induced by sympathomimetics and corticosteroids used in the management of preterm labor. As it is entirely fetal blood, this may result in fetal exsanguination and even death. Any drug ingested by a nursing mother may be present in her breast milk, but its concentrations are usually low compared to blood levels in the mother. However, anti-D may not be required in a case with complete miscarriage before 12 weeks of gestation where no instrumentation has been done. There is relative fall in the level of hemoglobin and hematocrit during pregnancy. The majority of differentiated effector T lymphocytes are short lived and not self-renewing. The characteristic landmarks are the feeling of the ribs and intercostal spaces (grid iron feel). Radiotherapy for symptom palliation Radiotherapy is used to control some symptoms caused by metastatic disease. Audit (clinical review) is an effective tool to indicate that change is essential. Pyroptosis also results in the death of certain microbes that gain access to the cytosol. It may be associated with increased intake of starch, though actual cause is not known. Thus, supplementary iron therapy is needed for all pregnant mothers from 16 weeks onwards. The classical features of bleeding in placenta previa are sudden onset, painless, apparently causeless and recurrent. Simultaneous perineal and vulval infiltration is needed to block the perineal branch of the posterior cutaneous nerve of the thigh and the labial branches of the ilioinguinal and genitofemoral nerves (vide supra). Fertility-sparing surgery In young women who are keen to preserve their fertility, fertility-sparing surgery. The area lateral to the occipitotemporal sulcus is called the lateral occipitotemporal gyrus.