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Ventilation may be needed if a muscle relaxant has been given during an operation as part of general anaesthesia. Alle rg ic de rmatitis Sensitivity to soap (usually perfum ed), som e detergents used to wash underclothes, and other contact allergens m ay cause vulval itch. If the patient has a prolapse, the degree of the vaginal wall or uterine descent can best be assessed if a Sim s speculum is used, with the patient in the left lateral position. Some so-called sports injuries, such as tennis elbow, are in fact a type of overuse injury. In many cases, wisdom teeth are unable 599 to emerge fully from the gum as a result of overcrowding (see impaction, dental). Som e wom en feel faint when lying on their backs in late pregnancy because the pressure of the uterus reduces venous return to the heart (supine hypotension). Situated behind the cochlea are 2 sacs (the saccule and the utricle) and 3 fluid-filled semicircular canals, all of which are concerned with balance. In addition, health authorities recom m end that wom en over 35 have an annual breast exam ination by a doctor. Treatment aims to lower the levels of fats in the blood by means of a diet that is low in cholesterol and high in polyunsaturated fat, and by drug treatment. The main forms of open heart surgery are correction of congenital heart defects (see heart disease, congenital), surgery for narrowed or leaky heart valves (see heart-valve surgery), and coronary artery bypass surgery. For those born 20 years earlier the survival rate was 25%; disability rates were m ild 33%, m oderate 13% and severe 15%; cerebral palsy 14%, blindness 7% and dea ness 5%. Genital warts have been linked with the development of cervical cancer (see cervix, cancer of). They are also used in the treatment of women with mixed incontinence, and less commonly for urge incontinence. More recently, second-generation (non-hysteroscopic) ablation techniques are widely used because of a better safety profile compared with first-generation techniques. A psychiatric evaluation and a physical examination are necessary before such treatment is undertaken. Acute inflammation has local and systemic effects, both of which may be harmful or beneficial. Chronic kidney failure can result from a disease that causes progressive damage to the kidneys, such as hypertension, longstanding obstruction to urine flow, and excessive use of analgesic drugs. White adipose tissue form s the subcutaneous cover of the body of a term fetus, but in preterm babies the layer m ay be thin. Heart murmurs are regarded as an indication of possible abnormality in the blood flow. The breast is gently flattened between an X-ray plate and a plastic cover so that as much tissue as possible can be imaged. It is rare for a venomous animal to attack a person unless it has been provoked or disturbed. An artery, vein, and nerve run down each side of the toe, and the whole structure is enclosed in skin with a nail at the top. Herbal remedies need to be used with caution in women with a contraindication to oestrogen, as some botanicals have oestrogenic properties. The population prevalence of some degree of sexual dysfunction is estimated to be approximately 20%. Heating cells introduces free energy and causes macromolecules to vibrate and break. Presbyopia is usually noticed around age 45 when the eyes cannot accommodate to read small print at a normal distance. Evidence level B, inconsistent or limited-quality patient-oriented evidence; considerable variation and lack of coherence; high-quality systematic reviews and meta-analyses, if they exist, do not find consistent evidence in favour of recommendation. If the woman does not wish to continue with the method, it can be removed with the next period or when an alternative method has been established.

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For the first 8 weeks of pregnancy, the developing baby is called an embryo; thereafter it is called a fetus. Sometimes, loose 441 teeth can be anchored to firmer teeth by splinting (see splinting, dental). At the sam e tim e the oocyte undergoes another division of its chrom osom es and a second polar body is form ed. The substances produced include important proteins for blood plasma, such as albumin. In severe dehydration, or if the patient cannot take fluids by mouth because of nausea or vomiting, an intravenous infusion of saline and/or glucose solution may be given in hospital. If the strain is not too great the ligam ents have considerable tensile strength, but if the strain is increased or the ligam ents are dam aged, they stretch. The Royal College of Obstetricians and Gynaecologists (2004) issued guidelines for the management of tubal pregnancy. If the infection spreads from the cervix it m ay involve the param etrium or the pelvic cellular tissues. For neonatal deaths the two m ost frequent factors were inadequate resuscitation and inadequate paediatric m anagem ent. In these cases Re curre nt candidiasis Between 5 and 15% o wom en with vaginal candidiasis have recurrent attacks, som etim es our tim es a year. The m enarche m ay be delayed in wom en who are o low body weight, such as ballet dancers, wom en who have anorexia nervosa, or those who are com pulsive exercisers. In others, low drive is due to a traum atic sexual experience in childhood or adolescence. The pelvic floor muscles are those that tighten when urine flow is stopped midstream. Migraine sufferers 396 commonly experience a form of neuralgia consisting of attacks of intense, radiating pain around the eye. Stovall and Ling (1993) found that the administration of methotrexate to patients who had a fetal heartbeat on ultrasound scan was associated with a 14. Zinc oxide is used to treat painful, itchy, or moist skin conditions and to ease the pain caused by haemorrhoids and insect bites or stings. The depression ranges from an extremely common and mild, shortlived episode ("baby blues") to a rare, severe depressive psychosis. Any foreign material or infection stimulates the inflammatory reaction further and directs it down the most suitable pathways such as pus formation, foreign body giant cell reaction or granulomatous reactions to mycobacteria and fungi. Duffy S, Marsh F, Rogerson L et al 2005 Female sterilization, a cohort controlled comparative study of Essure versus laparoscopic sterilization. In recent years a num ber of younger wom en have been presenting with m alignant change in a vulval condylom a. As the tumour grows, it may develop into an ulcer or a deep fissure, which may bleed and erode surrounding tissue. It is uncommon and may be caused by various disorders that can result in production of sex hormones at an abnormally early age. The results of epidemiological studies performed over the last 50 years give a variable incidence for dysmenorrhoea. Prognosis: 30% may remit after successful treatment of the first episode; in nonremitters, subsequent episodes of depression become more severe and prolonged B. Chronic haemolytic anaemia causes fatigue, headaches, shortness of breath on exertion, pallor, and jaundice. This includes basic advice such as storing, preparing and cooking foods at the appropriate tem peratures, and avoiding foods that m ay not be cooked thoroughly, that is, foods from takeaway shops, m eat pies and salads. The area o endom etrium supplied by the spiral artery becom es hypoxic, and ischaem ic necrosis occurs.

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Fibrin formation occurs during the process of menstruation (Beller 1971, Sheppard et al 1983). The colposcope is placed in front of the vagina and its focal length is adjusted to exam ine the suspect part of the lower genital tract (see p. Each portion of the breast should be palpated system atically, beginning at the upper, inner quadrant, followed by palpation of each portion sequentially until the upper, outer quadrant is nally exam ined. A limp in a child should always be seen within 24 hours as it may result from a hip problem that requires treatment. Evidence level C, consensus, usual practice, opinion, disease-oriented evidence or case studies; disease-oriented evidence measures intermediate, physiological or surrogate endpoints that may or may not reflect improvements in patient outcomes. Once the body has becom e habituated to the new horm onal environm ent, the nausea and vom iting usually cease. The cause is thought to be bacterial; affected tissues are found to contain macrophages (a type of scavenging cell) containing rod-shaped bacteria. Since Cerazette inhibits ovulation in almost all cycles, the theoretical risk of ectopic pregnancy is less. It may also be a symptom of an emotional problem or be part of the disorders anorexia nervosa or bulimia. Occasionally, there is an underlying cause (such as an infection or, very rarely, cancer) that requires treatment. Genetic counselling is advised for parents or other close relatives of a child with thalassaemia, and also for any person with thalassaemia trait. In some situations the persistence of infection in a chronic form can prevent healing from ever taking place; for example, chronic osteomyelitis following a compound fracture may persist for decades without resolution. The acidosis may result in osteomalacia, kidney stones (see calculus, urinary tract), nephrocalcinosis, and hypokalaemia (an abnormally low level of potassium in the blood). Lubricants must be applied frequently for more continuous relief, and require reapplication before intercourse. Examples of notifiable infectious diseases are food poisoning, hepatitis, measles, malaria, tetanus, tuberculosis, and pertussis (whooping cough). It is also possible that women using the pill have their tumours diagnosed earlier, although it is difficult to explain why a tendency to earlier diagnosis would persist for years after discontinuation. Traditionally unfractionated heparin was used but it has the disadvantage that for prophylaxis it needs to be given twice a day (or even three times for high risk patients) and if used therapeutically is ideally given by the i. Chest tapped potassium channel to loosen secretions activators A class of drugs that are used in the prevention and longterm treatment of angina. Nine of these patients had an ectopic pregnancy at laparoscopy, and of these, 3D transvaginal ultrasound showed a small ectopic gestational sac in four cases. For som e it m ay be a fear of the pain of labour, for others to avoid any risk of pelvic oor dam age during delivery, or a perception that abdom inal delivery rem oves all risks for the baby. Obesity is associated with some hormonal disorders, but these are not generally the cause. Romero R, Kadar N, Jeanty P et al 1985 Diagnosis of ectopic pregnancy: value of the discriminatory human chorionic gonadotropin zone. Sebum lubricates the skin, keeps it supple, and protects it from becoming waterlogged or dried out and cracked. Women screened for the clinical trial who were ineligible or unwilling to participate in the controlled trial (n = 93,676) were recruited into an observational study that assessed new risk indicators and biomarkers for disease. The multinucleate giant cells resulting have little phagocytic activity and no known function. In adolescence the classic features are short stature and arrested or delayed puberty. With the developm ent of m ore m odern contraceptives its frequency has declined, but it is still the preferred m ethod in som.

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For example, infant mortality measures the deaths of live-born infants during the 1st year of life. This prospective rating is best achieved by use of the Daily Record of Severity of Problems form. Complications the most significant complications are those of uterine perforation and fluid absorption. Deficiency in young children causes rickets; long-term deficiency in adults leads to osteomalacia. Hammarback S, Backstrom T, Hoist J et al 1985 Cyclical mood changes as in the premenstrual tension syndrome using sequential oestrogen - progestagen postmenopausal replacement therapy. Both are m ediated by psychic or physical sexual stim ulation or, m ore usually, by both. They include m assage and touch, relaxation techniques, rhythm ical m ovem ents, heat and cold. The baby is presented to the parents clothed and wrapped, and when they becom e accustom ed to him or her, the baby can be undressed by them. Respiratory arrest leads to anoxia and, if untreated, cardiac arrest, brain damage, coma, and death. The wom an is transferred from the adm ission room to a bed in a delivery room (if she has not already been adm itted to it), and a partogram is started which shows the progress of labour at a glance. Bergman glia: form shells around the Purkinje cell bodies, exposing only synaptic sites; also serve to guide granule cell migration during development b. Two protective discs of cartilage called menisci (see meniscus) cover the surfaces of the femur and tibia to reduce friction. Recommended therapy for vulval pain syndromes is multidisciplinary with psychosexual input in coordination with gynaecological treatment (Nunns 2000). In the chronic orm, atrophy o the urethral tissues m ay perm it the external urinary m eatus to gape and allow the posterior urethral wall to prolapse. Most calcium deposits are calcium phosphate in the form of hydroxyapatite and contain small amounts of iron and magnesium and other mineral salts. Suppositories are used to treat rectal disorders such as haemorrhoids or proctitis. Under transvaginal ultrasound scanning, a galactose solution is injected into the uterus and passes along the Fallopian tubes. Because of this a wom an has the right to know that analgesics and anaesthetics are available for her, and she can decide when she needs pain relief. The disorder causes stunted growth, emaciation, and loose folds of skin on the limbs and buttocks due to loss of muscle and fat. Water im m ersion during the rst stage of labour reduces the use of analgesia but does not affect the duration of labour, the rate of operative delivery or neonatal outcom. Bacterial mastitis during breast-feeding also causes redness and engorgement and may result in a breast abscess. Early detection is the only way to control the disease, as by the tim e the cancer can be palpated easily, spread is likely to have occurred. The cell is a highly-structured complex of molecules and organelles that are arranged to fulfil routine metabolic housekeeping functions and the specialised functions that make one cell different from another. If the physician intends to take a cervical sm ear to exam ine the exfoliated cells, or a vaginal and cervical swab for m icrobiological exam ination, no lubricant apart from water should be used on the speculum. Early referral to a paediatric urologist is required; under no circum stances should circum cision be perform ed, because the residual foreskin is required for the repair of the urethral defect. There is a paucity of evidence on whether the bene ts of treatm ent of otherwise healthy wom en with m ild iron de ciency anaem ia outweigh the adverse effects that include nausea and constipation for oral iron, venous throm bosis and allergic reactions for intravenous iron and pain and skin discolouration for intram uscular iron. Treatment the treatment depends on the cause and falls into four basic categories: chemical, mechanical, surgical and psychosexual. Ovulation should be confirmed and a normal semen analysis should be obtained from the partner before reversal is undertaken. Inhibite d se xual de sire and aro usal the m ost used approach is to involve both partners when possible. Vasopressin increases prostaglandin synthesis and m ay act on the uterine arteries directly.

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Cytologic examination Cytological examination is normally used to diagnose asymptomatic intraepithelial lesions of the cervix. In retention, important information is transferred into long-term memory and stored. Weight may be an important factor in the presentation of women with hirsuties, and should be considered in the treatment possibilities since weight gain or difficulty in weight loss is experienced with oral contraceptive therapy. Suggesting joining a support group or re erring to a counsellor experienced with breast cancer survivors can be help ul. Postmenopausalwomen A different strategy is required for postmenopausal women because, unlike younger women, they cannot be stratified on the basis of menstrual pattern. The involuntary m uscle that form s the bladder can be divided into two parts, that form ing the fundus, which is poorly supplied by autonom ic nerves, and that form ing the base (the detrusor m uscle), which is richly supplied by autonom ic nerves. The frontal and temporal lobes and anterior hypothalamus are all shown to have some function in mediating the sexual response, but the extent of this is still unclear. Galactorrhoea (milk discharge in someone who is not pregnant or breast-feeding) may be caused by a hormone imbalance, or, rarely, a galactocele (a cyst under the areola). The proportion of m uscle begins to dim inish in the isthm us, and connective tissue appears in increasing am ounts. The uterus can contract without m otor nerve stim ulation, as occurs in labour in paraplegic wom en. Tumor location: arise from the septum pellucidum and 3rd ventricle, often filling lateral ventricles and obstructing cerebrospinal fluid outflow through foramen of Monroe; rarely involves periventricular brain parenchyma, and symptoms are usually due to hydrocephalus 2. In a few cases of severe bleeding the blood is forced by intra-uterine pressure between the myom etrial bres towards the serosal layer of the uterus. An enlarged prostate (see prostate, enlarged) may cause symptoms including difficulty in starting to pass urine, poor urine flow, and increased frequency of urination. One form of the disease, which occurs in West and Central Africa, takes a slow course, with bouts of fever and lymph node enlargement. The effects of partial trisomies depend on the amount of extra chromosomal material present. Optic disc: the collection of retinal ganglion cell projections (still unmyelinated); normally forms the blind spot located in the temporal visual field a. Due to this, normal tissue, with a much lower mitotic rate, will lose a very small percentage of cells compared with the tumour. High doses of antibiotic drugs (commonly cotrimoxazole) may eradicate the infection; they may also be used over the long term to prevent infection in those people at increased risk. Nipple inversion that develops in older women is mostly due to ageing, but mammography may be advisable to rule out the possibility of cancer. Lens dislocation is almost always caused by an injury that ruptures the fibres connecting the lens to the ciliary body. The syndrome is caused by inflammation of 1 or several rib cartilages and symptoms may persist for months. The most common form, epidemic keratoconjunctivitis, is caused by a virus and is highly infectious. Atrophic and inflammatory vulvar and vaginal lesions can be visualized, and cervical polyps and invasive lesions of cervical carcinoma that may present with irregular bleeding can be seen. In very old wom en, only a narrow cleft indicates the presence of the vaginal introitus. Urethral valves m ay present in utero with oligohydram nios due to severe urethral obstruction; but less severe obstruction m ay present postnatally with poor urine stream, enlarged bladder and/or urinary infection. The sliding movement of the symphysis is shown when (A) the patient stands on her right leg; (B) the patient stands on her left leg. Firstly, the effect on hair growth takes several months to become apparent and only partial improvements may be expected. In most cases, the condition can be improved with topical treatments, such as those containing corticosteroid drugs and coal tar. Peritoneum Ureteric orifices Muscle Mucosa joint by the ligam ents of the joint, the psoas m uscle and the com m on iliac vessels, and enter the pelvis in front of the com m on iliac artery at its bifurcation into the external and internal branches. There is evidence of sim ilar m alform ations (particularly facial dysm or phism, hypoplastic ngernails and shortened phalanges) in the fetuses of wom en with epilepsy who have not taken drugs.

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It is performed to treat enlargement of the gland (see prostate, enlarged), cancer of the prostate (see prostate, cancer of), or prostatitis. In Australia births to wom en aged 30 years and above in 2012 accounted for 55% of all births com pared with 42% in 1994. Implantation in the middle segment involves a greater mass of myometrium and permits the pregnancy to advance to a somewhat later date. Mucinous cystadenoma these cysts occur m ost frequently between the ages of 35 and 55. Presentation Loss of libido may present as depression or as a relationship problem. There are associations between loss of desire and hormonal status in postmenopausal women. Physiotherapy is needed to prevent or limit deformity or to help relieve symptoms and maintain mobility. Keeping a diary can help pinpoint trigger factors, and prophylactic drugs may be prescribed. Orthopnoea is a symptom of heart failure and pulmonary oedema, 420 and also occurs with asthma and chronic obstructive pulmonary disease (see pulmonary disease, chronic obstructive). Bone strength reflects the integration of two main features: bone density and bone quality. One gray is equivalent to 100 rad (the older dose unit of radiation absorbed dose). The blood loss due to hookworm is related closely to the hookworm load, and varies from 2 to 90 m L/day. The movement shows a directional response (chemotaxis) to the various chemicals of acute inflammation. Each testis is suspended by the spermatic cord, composed of the vas deferens, blood vessels, and nerves. Rare infectious diseases that are more common in certain jobs include brucellosis and Q fever (from livestock), psittacosis (from birds), and leptospirosis (from sewage). The inconvenience Treatment to the patient and the cost to both the patient and the health services need to be balanced against the high levels of satisfaction that are reported after hysterectomy (Lethaby and Farquhar 2003). Letrozole has been found to be at least equally effective as clom ifene for ovulation induction and is an option for ovulation induction in wom en who fail to conceive with clom ifene. With the closure of the ductus venosus, the foram en ovale and the ductus arteriosus, the adult pattern of circulation of the blood is established. This may be due to disease (for example, a pulmonary embolism) or medically induced. As well as symptoms and signs common to acute forms of leukaemia (see leukaemia, acute), there may be enlargement of the liver and spleen, persistent raised temperature, and night sweats. Worldwide, contamination of drinking water is an important mode of transmission for various diseases including hepatitis A, many viral and bacterial causes of diarrhoea, typhoid fever, cholera, amoebiasis, and some types of worm infestation. The tendon is cut from its original point of attachment and reattached elsewhere, making the muscle lie in a different position. Additional factors are physical illness, the fear that sex will aggravate an existing illness, excessive alcohol use, or clinical depression and anxiety. Vulval in ections are the m ost com m on, although the virus m ay spread to in ect the vagina, the perineum. If an abnorm al sm ear is reported, the need to counsel and explain is im perative. To reduce these variables, blood pressure recording equipm ent should be calibrated regularly, cuffs checked and the blood pressure taken with the patient seated or reclining with her arm at heart level. In cases of severe bleeding, urgent treatm ent to deliver the baby (and the placenta) is required, irrespective of the 120 Chapter 1 3 Antepartum haem orrhage gestational age of the fetus. The main danger of such an injury is the possibility that the broken bone may be driven inwards, damaging the heart, which lies behind the sternum. In the face presentation engagement occurs late, as the parietal prominences do not enter the brim until the face has reached the pelvic oor.

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In m ost cases this has no clinical signif cance, but occasionally m ay be ound in wom en who have antepartum or intrapartum haem orrhage. This is actually relatively common but significant clinical consequences are rare. The pain m ay be alleviated with night splints and in m ore severe cases with injection of dexam ethasone. These changes occur in the female after puberty and probably develop to a small extent in all women. Later in pregnancy m any wom en fear that the baby will be m alform ed or intellectually disabled, or that childbirth will be dangerous and painful. Various histological patterns of adenocarcinom a are found on the histological exam ination of an endom etrial biopsy or curettage. In addition to the risk of thrombosis on a complicated plaque there is also a risk from haemorrhage within it, and when it occurs it causes the plaque to protrude even further into the lumen. Radioactive iodine Normal cells suffer little or no longused to treat thyrotoxicosis is given in term damage, but short-term damage is liquid form and drunk through a straw. The rem aining 40% have severe m enopausal sym ptom s, the severity of which is loosely related to the circulating level of oestradiol, and usually they occur if the level is <60 pm ol/L. The roots of the tooth, which fit into the jawbone, are covered by bone-like cementum. Brain swelling may be controlled by corticosteroid drugs and by intravenous infusions of mannitol. Subdermal implants the synthetic progestogen etonogestrel (Im planon or Nexplanon, which is radio-opaque) is placed under the skin of the inner aspect of the nondom inant upper arm under a local anaesthetic. Manual wheelchairs are designed so that the hand-rims can be easily gripped by a disabled person. Shapiro S 2007 Recent epidemiological evidence relevant to the clinical management of the menopause. The gold standard treatm ent is local excision as up to 20% are found to have unrecognized invasive disease. T atme nt re Treatm ent consists of suppressing ovulation, by prescribing an oral contraceptive or by inhibition of prostaglandin synthesis by one of the prostaglandin synthetase inhibitors, m efenam ic acid, ibuprofen, diclofenac sodium or naproxen. Such marks, which may be temporary, are a type of haemangioma and are usually found around the eyes and at the nape of the neck. The spasms are caused by a biochemical disturbance and are painless at first; if the condition persists, the spasms tend to become increasingly painful. Methods of investigating the kidneys include kidney biopsy, kidney function tests, and kidney imaging techniques such as ultrasound scanning and intravenous urography. A meta-analysis has demonstrated that a single serum progesterone measurement is good at predicting a viable intrauterine or failed pregnancy, but is not useful for locating the site of pregnancy (Mol et al 1998). It is used to detect abnormalities or diseases of the veins, such as narrowing or blockage from thrombosis. Postdelivery dyspareunia is reported frequently but, on average, women resume sexual intercourse at 7 weeks post partum (Byrd et al 1998). Localized osteosclerosis may be caused by a severe injury that compresses the bone, osteoarthritis, chronic osteomyelitis, or an osteoma. The earlier the infection occurs, the more likely the infant is to be affected, and the more serious the abnormalities tend to be. Little is known about their efficacy and safety in women with premature menopause and effects on the developing fetal skeleton. From the 20th week growth alm ost ceases and the uterus expands by distension, the stretching of the m uscle bres being due to the m echanical effect of the growing fetus. Some bacterial capsules physically block access of phagocytes to C3b deposited on the bacterial cell wall. If the wom an seroconverts, the problem s of congenital infection should be discussed with her and a therapeutic abortion is an option she m ay wish to consider. The clinical effects of infections are m icrocephaly, congenital heart disease, eye dam age (such as cataract), deafness, hepatosplenom egaly (with jaundice), purpura and, later in childhood, m ental handicap. This is an important part of rehabilitation for people with mental handicap or those with chronic psychological disorders, such as schizophrenia.

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A vagal reflex inducing spasm of the coronary and pulmonary arteries, perhaps associated with peripheral vasodilatation, has been suggested. T atme nt re Antibiotics are adm inistered at once, the precise one cho sen depending on local conditions, but in general a broad acting antibiotic and one effective against anaerobes are selected. Approximately 24 h premenstrually, intense vasoconstriction led to ischaemic damage, followed by vasodilatation with haemorrhage from both arterial and venous vessels: 75% of the loss was arteriolar, 15% was venous and 10% was diapedesis of erythrocytes (Markee 1940). Growth restriction in late gestation, low weight gain in infancy, starvation in early childhood and smoking may be associated with an earlier menopause. It is often the result of a psychiatric illness, such as severe depression or schizophrenia. However, the laparoscopic approach is significantly less costly than open surgery. This system is in turn part of the reticuloendothelial system which refers not only to the phagocytic cells, but also to interdigitating reticulum cells of lymph nodes and the endothelial cells in lymphoid organs. I these babies are born be ore term they are m ore likely to develop the respiratory distress syndrom e because there is delayed resorption o lung f uid, which causes transient tachypnoea in the newborn baby. The term noninvasive is sometimes also applied to noncancerous tumours that do not spread throughout body tissues. Its precise aetiology remains largely unknown, but it is likely to be due to a combination of factors, including destruction of the trophoblastic tissue and transtubal haemorrhage leading to peritoneal irritation. This deficiency causes breathing difficulties, and the infant needs artificial ventilation and the administration of an artificial surfactant. Disruption of the activity of some neurotransmitters in the brain is a possible mechanism. There are often no symptoms, but sometimes there is a dragging feeling in the pelvis. This treatment cannot be recommended in view of the risks of hepatic toxicity during long-term therapy. It is usually 455 mild, but in serious cases, it attacks the brain and spinal cord, sometimes causing paralysis or death. This throws a considerable strain on the sta, who have to m ake sure that the baby will not be harm ed. Varicose veins may require surgical removal if they become painful or ulcerated, but they may later develop elsewhere. Usually, the sting causes only a mildly painful or itchy rash, but some jellyfish and Portuguese men-of-war (other members of the same group) can cause a severe sting. A patient with these signs is acutely ill and should be transferred to an intensive care unit without delay. To some extent such behaviour is common in adolescence, but when law-breaking or violence occur the condition is deemed to be pathological. Synchronicity of menstruation in women living together, possibly due to pheromonal influence, has been documented (McClintock 1998). Neuralgia is sometimes relieved by analgesic drugs (painkillers) such as paracetamol. These oral medications have reported efficacy rates of approximately 70% for sexual intercourse. If screening is chosen, it is emphasized that antibiotic therapy should be started before abortion is performed. They often rem ain pain free when the uterus becom es retroverted again, as it usually does. In many cases, another part of the spine curves to compensate, resulting in an S-shaped spine. The m aternal exam ination includes inspection of the perineum and vagina to ascertain that any dam age has healed, to nd out whether she has urinary or faecal incontinence, and to determ ine the m uscle tone.