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Once the diagnosis is suspected what causes erectile dysfunction yahoo buy levitra oral jelly with a visa, referral to a paediatric cardiologist is essential erectile dysfunction doctor in philadelphia cheap levitra oral jelly 20 mg otc. The development of hydrops is a poor prognostic sign and termination of pregnancy should be discussed. This is an extremely complex process influenced by both genetic and environ mental factors and continues ex utero for several years. It occurs in 1 in 4000 individuals and has been estimated to have a prevalence of 1. It may occur in isolation, associated with aneuploidy, as part of a genetic syndrome. Counselling by a paediatric neurologist is essential as the spectrum of potential problems is wide. There is an association with a variety of genetic syndromes, chromosomal abnormalities, infec tions and environmental teratogens. There is incom plete division of the cerebral hemispheres with a single midline forebrain ventricle (monoventricle), which often communicates with a dorsal cyst. The frontal horns of the lateral ventricle are absent, but posterior horns are present. Genetic counselling is essential and prenatal diagnosis may be an option in selected cases. Neurodevelopmental outcome for mild isolated ventriculomegaly (<15 mm) appears to be not significantly different from the general population. However, asymmetric bilateral ventriculomegaly may carry a worse prognosis, with these children at significant risk for behavioural abnormalities. Poor prognostic factors include coexistent cerebral anomalies and progression of the ventriculomegaly. In severe ventriculomegaly, the outcome may still be variable but less than 30% of children will develop normally. Termination of preg nancy should be discussed for severe ventriculomegaly (>15 mm), aneuploidy, spina bifida or other associated major malformations. In the presence of severe macrocephaly, caesarean section or cephalocentesis may be required. Cephalocentesis is associated with a high incidence of procedural/intrapartum demise. Neural tube defects [7,8] Depending on the gestational age at ascertainment, the prevalence of ventriculomegaly varies between 0. Ventriculomegaly is defined as a measurement of the atrium of the posterior or anterior horns of the lateral ventricles of more than 10 mm at any gestation. In fetuses with apparently isolated unilat eral ventriculomegaly, increased dilatation of the ventricles occurs in 5% of cases. Once detected it is important to obtain a detailed history, especially of recent viral illness or significant maternal trauma, family genetic history, previous congenital abnormality or fetal/ neonatal thrombocytopenia. For isolated unilateral ventriculomegaly, additional brain abnormalities are Most neural tube defects are multifactorial in origin, with a genetic component that interacts with a number of envi ronmental risk factors. Between 2 and 16% of isolated open neural tube defects occur in association with aneuploidy or a single gene defect. Some neural tube defects are lethal (anencephaly, craniorachischisis) whereas others are compatible with longterm survival. However, there is risk of significant morbidity, including mobility issues and bladder and bowel dysfunction, and counselling by a neurologist is essential. Prenatal surgical closure of selected cases of mye lomeningocele is now an option, with evidence of significant reduction in the need for ventriculoperitoneal shunting compared with standard postnatal closure. In addition, prenatal surgery improves reversal of hind brain herniation as well as ambulation by 30 months. However, prenatal surgical intervention is associated with significantly higher rates of oligohydramnios and chorioamniotic separation, as well as spontaneous mem brane rupture and preterm delivery. The diagnosis is suspected on ultrasound when polyhydramnios and a doublebubble appearance (due to a dilated stomach and proximal duodenum) are present. Duodenal atresia results from failure of reca nalization of the duodenum after the seventh week of gestation, possibly due to an ischaemic event; occasion ally, genetic factors may also play a role. Although sometimes seen earlier in gestation, the diagnosis is usu ally made after 24 weeks. Approximately 50% of cases of duodenal atresia have associated structural anomalies. Because of the sig nificant risk of polyhydramnios (50%), regular scans are required and amnioreduction may be necessary if the amniotic fluid index increases substantially or if the patient is symptomatic. Delivery should take place in a tertiary centre with neonatal and paediatric surgi cal facilities. After birth, a nasogastric or orogastric tube is placed to decompress the stomach to minimize aspiration, and routine supportive management usually includes administration of intravenous fluids. Once clinically stable, surgical repair via laparotomy or lapa roscopy is performed. Intraoperatively, it is important to exclude any associated malrotations, other small bowel atresia, or an annular pancreas. The longterm prognosis for duodenal atresia is very good, with sur vival rates of approximately 90%. Meconium ileus/peritonitis [10,11] diagnosed, appropriate genetic counselling should be offered and termination of pregnancy discussed if the diagnosis is made early in pregnancy. In the simple form, thick ened meconium begins to form in utero, and results in obstruction to the midileum that causes proximal dilatation, bowel wall thickening, and congestion. In complicated cases, thickened meconium and obstruc tion lead to complications such as segmental volvulus, atresia, necrosis, perforation, meconium peritonitis (generalized) and giant meconium pseudocyst forma tion. In infants with cystic fibrosis the longterm outlook is guarded because of other extraabdominal complica tions that can develop. Abdominal wall defects Omphalocele (exomphalos) [12,13] Meconium ileus is impaction of abnormally thick meco nium in the distal ileum. Meconium peritonitis occurs when there is perforation of bowel in utero, resulting in a sterile chemical peritonitis. Ultrasound features of meconium peritonitis include intraabdominal calcifi cations, hyperechogenic bowel, ascites and bowel dilatation. Serial ultrasound scans should be performed to assess progres sion of bowel dilatation, development of ascites or intraabdominal cysts and polyhydramnios, which might indicate complicated meconium peritonitis with a 50% chance of requiring neonatal surgery. If these are pre sent, consideration should be given to delivering the baby in a tertiary centre with neonatal surgical facilities. Parental cystic fibrosis carrier testing and/or invasive fetal testing should be offered. If cystic fibrosis is this is a midline anterior abdominal wall defect of vari able size characterized by the absence of abdominal muscles, fascia and skin. A defect in cranial folding results in a high or epigastric omphalocele, classically seen in pen talogy of Cantrell (epigastric omphalocele, anterior diaphragmatic defect, sternal cleft and pericardial/ cardiac defects). Lateral folding defects result in a midabdominal omphalocele and caudal defects cause a hypogastric omphalocele seen in bladder or cloacal exs trophy. The larger the defect, the higher the risk of postnatal complications, such as pulmonary hypoplasia and res piratory insufficiency and an increased prevalence of neurodevelopmental delay.

The age of onset of anorexia nervosa is also important green tea causes erectile dysfunction buy cheap levitra oral jelly on-line, as prolonged amenorrhoea before the normal age at which peak bone mass is obtained (approximately 25 years) increases the likeli hood of severe osteoporosis xalatan erectile dysfunction cheap 20 mg levitra oral jelly with amex. Worldwide, involuntary starvation is the commonest cause of reduced reproductive ability, resulting in delayed pubertal growth and menarche in adolescents and infer tility in adults. Acute malnutrition, as seen in famine conditions, has profound effects on fertility and fecun dity. The chronic malnutrition common in developing countries has fewer profound effects on fertility but is associated with small and pre mature babies. Psychological stress Studies have failed to demonstrate a link between stressful life events and amenorrhoea of greater than 2 months. However, stress may lead to physical debility such as weight loss, which may then cause menstrual disturbance. Amenorrhoea is more common in athletes under the age of 30 years and is particularly common in women involved in the endurance events Polycystic Ovary Syndrome and Secondary Amenorrhoea 651 (such as longdistance running). Up to 50% of competi tive runners training 80 miles per week may be amenor rhoeic [30]. The main aetiological factors are weight and percent age body fat content, but other factors have also been postulated. Physiological changes are consistent with those associated with starvation and chronic illness. Ballet dancers provide an interesting subgroup of sportswomen, because their training begins at an early age. They have been found to have a significant delay in menarche (starting at the age of 15. In a survey of 75 dancers, 61% were found to have stress fractures and 24% had scoliosis; the risk of these pathological features was increased if menarche was delayed or if there were prolonged periods of amenorrhoea. These findings may be explained by delayed pubertal maturation resulting in attainment of a greater than expected height and a pre disposition to scoliosis, as oestrogen is required for epi physeal closure. Exerciseinduced amenorrhoea has the potential to cause severe longterm morbidity, particularly with regard to osteoporosis. Studies on young ballet dancers have shown that the amount of exercise undertaken by these dancers does not compensate for these osteoporo tic changes. Oestrogen is also important in the forma tion of collagen, and softtissue injuries are also common in dancers. Whereas moderate exercise has been found to reduce the incidence of postmenopausal osteoporosis, young athletes may be placing themselves at risk at an age when the attainment of peak bone mass is impor tant for longterm skeletal strength. Iatrogenic causes of amenorrhoea There are many iatrogenic causes of amenorrhoea, which may be either temporary or permanent. These include malignant conditions that require either radiation to the abdomen/pelvis or chemotherapy. Gynaecological procedures such as oophorectomy, hysterectomy and endometrial resection inevitably result in amenorrhoea. However, iatrogenic causes of ovarian quiescence have the same consequences of oestrogen deficiency due to any other aetiology. However, the demineralization is reversible with the cessation of ther apy, especially for the treatment of benign conditions in young women who are in the process of achieving their peak bone mass. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Polycystic ovaries and associated metabolic abnormalities in Indian subcontinent Asian women. Relative risk of conversion from normoglycaemia to impaired glucose tolerance or noninsulin dependent diabetes mellitus in polycystic ovary syndrome. Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of 20 21 22 23 24 25 26 27 28 29 30 31 ovulation in women with newly diagnosed polycystic ovary syndrome: randomized double blind clinical trial. Insulinsensitising drugs (metformin, rosiglitazone, pioglitazone, Dchiroinositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Results of ovulation induction using human menopausal gonadotropin or purified folliclestimulating hormone in hypogonadotropic hypogonadism patients. Hypersecretion of luteinizing hormone: a significant cause of infertility and miscarriage. Definitions of normality were described, nomenclature standardized, and underlying aetiologies classified in a structured manner. It is also important in clinical practice to distinguish between regular and abnormal bleeding, such as inter menstrual and postcoital bleeding. In addition to the direct effect on the woman and her family, there are sig nificant socioeconomic costs. Unfortunately, current medical therapy may be associ ated with undesirable side effects. The clas sification system accepts that women may have more than one underlying cause and also that where structural abnormalities are present, many women may in fact be symptomfree. Polyps Leiomyoma (fibroids) Polyps are common (incidence increasing with age), fre quently asymptomatic and their exact cause remains unknown. It is important to be aware that both polyps and fibroids may frequently coexist, and that polyps may be mistaken for submucous fibroids on ultrasound. Polyps may cause unpredictable intermenstrual bleeding as well as being associated with an increased volume of bleeding [5]. Theories include an increased endo metrial surface area and the presence of fragile and dilated vasculature around the fibroid [6]. Knowledge regarding the complex cellular and molecular changes found in association with fibroids is increasing. Data are emerging on the impact of uterine fibroid presence on angi ogenesis, on alteration in the production of vasoactive substances and growth factors, as well as modulation of coagulation. Adenomyosis is associated with increasing age and often coexists with endometriosis and fibroids. The most relevant premalignant condition that may cause abnormal bleeding is endo metrial hyperplasia. Sarcomas of myometrial origin, such as leiomyosarcoma, are rare but not infrequently present with abnormal bleeding in perimenopausal and Heavy Menstrual Bleeding 655 postmenopausal women. This is typi cally associated with continuous oestrogen or progestin therapies (intrauterine, systemic or oral delivery). These disorders may be inherited or acquired and severity of disorder varies (but the majority are mild to moderate). This aetiology should be considered in women who fail to respond to medical management and women who present at a young age. Currently, the use of antico agulants in women with thromboembolic disease also falls within this category. This most com monly occurs at the extremes of reproductive age (adolescence and perimenopause). Women in this group often report menstrual cycles that extend beyond 38 days or vary by more than 21 days. Endometrial dysfunction Inevitably, there are pathologies that do not easily fit within the categories described. Data exist to support an association between chronic endometrial infection and abnormal uterine bleeding, both intermen strual and heavy bleeding [5]. This is confounded by the fact that 85% of cases of chlamydial infection are asymptomatic. When they occur in the uterus they have been associated with episodes of acute excessive bleeding. These vascular lesions of the uterus pose difficult management decisions and may present with heavy uterine bleeding following early pregnancy loss.

All this results in dysu ria erectile dysfunction doctor dc generic levitra oral jelly 20mg on-line, urgency and frequency erectile dysfunction by race cheap 20mg levitra oral jelly visa, commonly termed the ure thral syndrome. The position statement from the International Menopause Society emphasizes the impor tance of enquiring about urogenital symptoms, the his tory of which might not be readily volunteered by the menopausal patient [9]. Long term Osteoporosis and sarcopenia Osteoporosis is a systemic skeletal disorder of the bone matrix resulting in a reduction of bone strength, to the extent that there is a significantly increased risk of fracture when a woman suffers a fall from her own body height. Osteoporosis is predominantly a disease of women, who achieve a lower peak bone mass than men and are then subjected to an accelerated loss of bone density following the menopause due to loss of oes trogen. Women lose 50% of their skeleton by the age of 70 years, but men only lose 25% by the age of 90 years. The loss of height occurs not only due to vertebral fractures but also loss of the intervertebral disc space as a result of deterioration and loss of collagen [12]. Osteoporosis related fractures cause considerable morbidity in the 674 Menstruation elderly, requiring prolonged hospital care and difficulties in remobilization. There is increasing awareness that avoiding sarcopenia (muscle loss and weakness) through regular exercise will maintain strength and posture and reduce the risk of injuries including osteoporosisrelated fractures. Hormone therapy may help muscle as well as bone strength but this requires confirmation [13]. Cardiovascular failure of oestrogen to show benefit for dementia in women commencing treatment above 60 years, and pos sibly an increased risk in some studies, may reflect the predominance of the prothrombotic effect of oestrogen in women of this age group. Cardiovascular disease is the principal cause of morbid ity and mortality in women. Women are protected against cardiovascular disease before the menopause, after which the incidence rapidly increases, reaching a similar frequency to men by the age of 70 years. As oestrogen levels begin to fall, the somatotrophic axis becomes less active leading to insulin resistance and a rise in central adiposity. A number of factors are involved in perimenopausal weight gain including genetic predisposition, socioeconomic influences, reduction in caloric need and expenditure, reduced lean body mass and a reduction in resting basal metabolic rate. Major primary prevention measures include smok ing cessation, weight loss, blood pressure reduction, reg ular aerobic exercise and diabetes and lipid control. Central nervous system Advances in prediction of menopause the prediction of menopause has progressed signifi cantly over the last 5 years. However, prediction models do not predict the extremes of menopause age very well and have wide prediction intervals. Markers need improvement before they can be used for individ ual prediction of menopause in the clinical setting. During the menopause transition, poor concentration and other cognitive problems are common [15]. Studies have demon strated that oestrogen may improve cerebral perfusion and cognition in women below 60 years. Oestrogen appears to have a direct effect on the vasculature of the central nervous system and promotes neuronal growth and neurotransmission. The Patient assessment and ongoing monitoring Initial diagnosis the diagnosis of natural menopause can usually be made from the characteristic history of the vasomotor symptoms of hot flushes and night sweats and/or amenorrhoea. Online programs such as Manage my Menopause can be helpful for both the woman and the healthcare professional in individualizing overall care and specific management [17]. An oestrogen level is only helpful if there has been inadequate response to treatment due to low levels or if side effects suggest that the dose of estradiol is too high. A white paper written by cardiologists and menopause experts has highlighted the important role that gynaecologists can play in cardiovascular screening [18]. Fasting lipid profile and estimation of insulin resistance are recom mended in women with risk factors. Although advice should be given to women about being aware of changes in their breasts and perineum, routine breast palpation and pelvic examination is unnecessary; these need only be performed if clinically indicated. Mammography should be performed as part of the national screening programme every 3 years unless more frequent examinations are clinically indicated. In women over 45 years of age it is best to arrange screening before starting oestrogen therapy to identify patients with subclinical disease. Markers of bone formation and breakdown can be useful in that changes occur more rapidly than with bone density, but their use is largely confined to research. Premature ovarian insufficiency Premature ovarian insufficiency remains poorly under stood and underresearched. However, as cure rates for cancers in childhood and young women continue to improve it is likely that the incidence of prematurely menopausal women will rise. It appears to be significantly higher, greater than 20%, in some Asian populations (personal communications with Indian Menopause Society and Chinese Gynaecological Endocrinology Society). One of the main reasons for this has been the 676 Menstruation bias of economic expenditure and medical endeavour to the prolongation of life. Should this trend continue we are in danger of cre ating a population of young women who have been given back the gift of life but left without the zest to live it to its full potential. These symptoms may not be typical vasomotor in nature and include mood distur bances, loss of energy and generalized aches and pains. A dedicated multidisciplinary clinic separate from the routine meno pause clinic will provide ample time and the appropriate professionals to meet the needs of these emotionally traumatized patients. Outcome measures should include vasomotor, urogenital, quality of life and psychosexual health and the longterm effect on cardiovascular, cog nitive and skeletal health. This is particularly important in women with rare causes and hormonesensitive cancers where randomized trials are unlikely to be ever performed. Interventions Lifestyle measures the modern approach to optimizing health in the meno pause should start from public education in school and the workplace. Commonsense lifestyle and dietary approaches instituted well in advance of the menopause will maximize that chances of good health through midlife and beyond. As recommended by the British Menopause Society position statement [28], every woman should be encouraged to take plenty of regular Menopause and Postmenopausal Health 677 exercise in addition to having a wellbalanced diet, avoiding smoking and minimizing alcohol consumption. Data suggest that women who are more active tend to suffer less from the symptoms of the menopause and have higher bone mineral densities compared with sed entary controls. However, excessive calcium intake can increase the risk of adverse events such as myocardial infarction [29]. Routine supplemen tation with calcium is not now recommended unless deficiency has been detected. Ensuring adequate vitamin D3 levels will not only improve calcium absorption but may also have a beneficial effect on general wellbeing and musculoskeletal symptoms. A reduction in alcohol and caffeine intake can also reduce the severity and fre quency of vasomotor symptoms. Route of administration There is a general consensus that the minimum effec tive dose of estradiol should be prescribed and the dose increased if required to alleviate symptoms. However, it is important that the dose is high enough to fully alle viate symptoms. Lower doses of oestrogen are less likely to cause breast tender ness and bleeding problems (due to less endometrial stim ulation), which will encourage continuation of therapy. The recommended starting doses of currently availa ble systemic oestrogen are as follows: Prior to the menopause the physiological state consists of an estradiol/estrone ratio of 2: 1. This can only be achieved if estradiol is delivered transdermally, thus avoiding firstpass hepatic metabolism. Oral estradiol preparations are partially metabolized to estrone by hepatic firstpass metabolism and therefore do not fully restore this ratio. This is particularly important in women who are obese or smokers and are therefore at increased risk of venous thromboembolic disease. The hormone is adsorbed onto the adhesive matrix and this avoids the skin reactions caused by the old alcohol reservoir patches. Dot matrix patches are the smallest and besttolerated patches, with a very low inci dence of skin irritation. Estradiol gel is also available either dispensed from a pump or as a lowvolume daily sachet. It is hoped that nonoral estradiol development will resume to produce commercially available nasal and sublingual tab/wafer products that also avoid firstpass hepatic metabolism. An expanded product armamen tarium facilitates individualized hormone replacement.

Small initial studies suggest there may be beneficial effects with thromboprophy laxis in terms of improved live birth rates [29 erectile dysfunction suction pump order 20 mg levitra oral jelly with mastercard,30] erectile dysfunction pills cialis buy levitra oral jelly 20mg with mastercard. However, thromboprophylaxis to prevent maternal thrombosis does need to be considered in women with multiple risk factors for this. Endocrinological factors Polycystic ovarian syndrome There is an association between polycystic ovarian syn drome and recurrent miscarriage. The possible mecha nisms for this are hyperandrogenism and insulin resistance [35]. However, the variation in criteria for diagnosing polycystic ovarian syndrome makes it diffi cult to assess the importance and the prognostic value of detecting it. Nevertheless, a simple, safe and cheap way to reduce pregnancy loss in obese women with polycys tic ovarian syndrome is weight loss [36]. Small studies suggest there may be a role for metformin in reducing miscarriage rates, especially in the presence of an abnor mal glucose tolerance test, and metformin is now regarded as having low risks in pregnancy [35,37]. A randomized controlled trial in infertile women indicated that clomifene is superior to metformin in achieving live births but made no differ ence to the rates of miscarriage [38]. Abnormalities of glucose metabolism and thyroid disorders It is known that wellcontrolled thyroid disorders and diabetes are not risk factors for recurrent miscarriage. Thus national guidelines do not recommend routine screening in the absence of symptoms [1,28]. Immunological factors Immunological mechanisms are thought to play a part in the success of pregnancy where the maternal immune sys tem interacts with the allogeneically dissimilar embryo. Antithyroid antibodies the presence of antithyroid antibodies has been associ ated with a higher pregnancy loss rate, the underlying mechanisms of which are either autoimmune or mild 572 Early Pregnancy Problems thyroid insufficiency [13,39]. A small study suggested that women with recurrent miscarriage and antithyroid antibodies but normal thyroid function tests may benefit from levothyroxine treatment [40] but further large scale trials are needed to substantiate this finding. A systematic review of 20 trials of various immuno therapies, such as paternal cell immunization, third partydonorcell immunization, trophoblast membrane infusion and intravenous immune globulin, showed no significant beneficial effect over placebo in improving live birth rates [44,45]. However, a recent systematic review showed no evidence of an improve ment in live birth rates in women with recurrent mis carriage [50] and in a randomized controlled trial there was a trend towards aspirin increasing the chance of miscarriage [32]. Progesterone Progesterone is needed for successful early pregnancy and thus a lack of progesterone could be surmised to lead to pregnancy loss. Endometrial factors It is long been suggested that defective implantation my contribute to recurrent early pregnancy loss. There is now evolving evidence that endometrial stem cells are depleted in cases of recurrent miscarriage, predisposing to pregnancy failure [46,47]. Early work on the role of chronic endometritis and recurrent miscarriage has sug gested improved live birth rates in treated cases [48]. Conclusions the management of recurrent miscarriage is challenging because of lack of evidencebased effective treatments. Couples with recurrent miscarriage can be offered inves tigations but the majority will be negative. Empirical treat ment in women with idiopathic recurrent miscarriage should be avoided and entry into highquality and meth odologically sound trials should be considered whenever possible in order to improve the evidence base for this distressing condition. Idiopathic recurrent miscarriage Tender loving care Women with recurrent miscarriage are anxious and appreciate reassurance when they fall pregnant again. Threequarters of these women with idiopathic recur rent miscarriage will achieve a live birth in the subse quent pregnancy, with tender loving care involving References 1 Royal College of Obstetricians and Gynaecologists. The Investigation and Treatment of Couples with Recurrent Firsttrimester and Secondtrimester Miscarriage. Reproductive outcome after chromosome analysis in couples with two or more miscarriages: index [corrected]control study. Systematic review and metaanalysis of genetic association studies in idiopathic recurrent spontaneous abortion. Preimplantation diagnosis and natural conception: a comparison of live birth rates in patients with recurrent pregnancy loss associated with translocation. Hysteroscopic metroplasty improves gestational outcome in women with recurrent spontaneous abortion. Reproductive outcome following hysteroscopic septal resection in patients with infertility and recurrent abortions. Does surgery improve live birth rates in patients with recurrent miscarriage caused by uterine anomalies The prevalence and impact of fibroids and their treatment on the outcome of pregnancy in women with recurrent miscarriage. Antiphospholipid antibodies and beta 2glycoproteinI in 500 women with recurrent miscarriage: results of a comprehensive screening approach. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Antithrombotic treatment for recurrent miscarriage: Bayesian network meta analysis and systematic review. Effects of enoxaparin on late pregnancy complications and neonatal outcome in women with recurrent pregnancy loss and 574 Early Pregnancy Problems 30 31 32 33 34 35 36 37 38 39 40 thrombophilia: results from the LiveEnox study. Thrombophilia and antithrombotic therapy in women with recurrent spontaneous abortions. Thromboprophylaxis for recurrent miscarriage in women with or without thrombophilia. Relationship between abnormal glucose tolerance test and history of previous recurrent miscarriages, and beneficial effect of metformin in these patients: a prospective clinical study. Natural killer cells in pregnancy 42 43 44 45 46 47 48 49 50 51 52 and recurrent pregnancy loss: endocrine and immunologic perspectives. Prognostic value of the measurement of uterine natural killer cells in the endometrium of women with recurrent miscarriage. Pregnancy outcomes in women with chronic endometritis and recurrent pregnancy loss. A longitudinal study of pregnancy outcome following idiopathic recurrent miscarriage. Aspirin or anticoagulants for treating recurrent miscarriage in women without antiphospholipid syndrome. A randomised, doubleblind, placebo controlled, international multicentre trial and economic evaluation. Despite this major progress, developments in manage ment of trophoblast disease are still required to help fur ther reduce toxicity, eliminate remaining deaths and refine diagnostic tools. The reported incidence of molar pregnancies in Europe and North America is on the order of 0. Similar data have been reported from other European countries where whole population analyses are possible [7]. Whilst there are some modest variations in the incidence of molar preg nancies based on race and geography, there are two clearly documented risk factors for an increased risk of molar pregnancy: the extremes of maternal age and a previous molar pregnancy [8,9]. The relative risk for molar pregnancies is highest at the extremes of the reproductive age group. Of interest, the risk of partial molar pregnancy remains relatively unchanged across the age group, with most of the change in overall risk due to an increased incidence of complete molar pregnancies. Per cent partial moles of viable conceptions Per cent complete moles of viable conceptions Premalignant pathology and presentation Partial mole the genetic origins of complete and partial molar preg nancies are demonstrated in. Partial moles are triploid with 69 chromosomes comprising two sets of paternal and one set of maternal chromosomes. Macroscopically and on ultrasound scanning during the first trimester, partial mole will often resemble normal products of conception. The histology of partial mole shows less swelling of the chorionic villi than in a complete mole and there may be only focal changes. As a result the diagnosis of partial mole can often be missed after a mis carriage or evacuation, unless the products are sent for expert pathological review. The clinical presentation of partial mole is most fre quently via a failed pregnancy rather than irregular bleed ing or by detection on routine ultrasound. Normal conception A single sperm with 23 chromosomes fertilizes an egg with 23 chromosomes Complete mole All 46 chromosomes are from the father May involve one or two sperm Monospermic complete mole 23 23 23 23 46 23 23 the maternal chromosomes are lost the paternal chromosomes double up 23 46 Partial mole Two sperms fertilize an egg this results in a triploid conceptus with 69 chromosomes Dispermic complete mole Fertilization by two sperm 23 23 23 23 23 23 46 23 23 23 23 23 46 the maternal chromosomes are lost.

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