Dictionary of Obstetrics and Gynecology 9783110857276, 9783110118759

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Dictionary of Obstetrics and Gynecology

Dictionary of Obstetrics and Gynecology Compiled by the editorial staff of Pschyrembel's Klinisches Wörterbuch Managing editor Christoph Zink Translated by Kathleen R. Dyer, Dietrich W. Roloff and Bernd Κ. Wittmann

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Walterde Gruyter· Berlin · New York 1988

Walter de Gruyter & Co. Pschyrembel Editions Genthiner Straße 13 D-1000 Berlin 30 This book contains 442 illustrations and 60 tables. Original edition: Pschyrembel Wörterbuch Gynäkologie und Geburtshilfe. Walter de Gruyter & Co., Berlin, New York, 1987

CIP-Titelaufnahme der Deutschen Bibliothek Dictionary of obstetrics and gynecology / comp, by the ed. staff of Pschyrembel's Klinisches Wörterbuch. Managing ed. Christoph Zink. Transl. by Kathleen R. Dyer... - Berlin; New York: de Gruyter, 1988 Dt Ausg. u. d. T.: Pschyrembel Wörterbuch Gynäkologie und Geburtshilfe. - Span. Ausg. u. d. T.: Diccionario Pschyrembel de ginecologia y obstetricia ISBN 3-11-011875-0 NE: Zink, Christoph [Hrsg.] Library of Congress Cataloging-in-Publication Data Pschyrembel Wörterbuch Gynäkologie und Geburtshilfe. English. Dictionary of obstetrics and gynecology. Translation of: Pschyrembel Wörterbuch Gynäkologie und Geburtshilfe. 1987. "Supplement to and extension of the Pschyrembel's Klinisches Wörterbuch"-Pref. 1. Obstetrics-Dictionaries. 2. Gynecology-Dictionaries. I. Zink, Christoph. II. Pschyrembel, Willibald. III. Pschyrembel, Willibald. Klinisches Wörterbuch. IV. Title. [DNLM: 1. Genital Diseases, Female-dictionaries. 2. Obstetrics-dictionaries. WQ 13 P974] RG45.P7813 1988 618.1'003'21 88-23720 ISBN 0-89925-533-7 (U.S.) © Copyright 1988 by Walter de Gruyter & Co., Berlin 30. All rights reserved, including those of translation into foreign languages. No part of this book may be reproduced in any form - by fotoprint, microfilm, or any other means - nor translated into a machine language without written permission from the publisher. The quotation of registered names, trade names, trade marks, etc. in this copy does not imply even in the absence of a specific statement - that such names are exempt from laws and regulations protecting trade marks, etc. and therefore free for general use. Data bank development: GSD mbH Berlin, Helmuth Schneider, Jörg Apitzsch Typesetting: SRZ, Satz-Rechenzentrum Hartmann + Heenemann KG, Berlin Reproductions: Terra-Klischee, Berlin Graphic design: Heiner Welz, Helmut Holtermann, Berlin Layout: Markus Strieder, Lutz-Olaf Walter, Berlin Printing and binding: Parzeller, Fulda Bookcover design: Lutz-Olaf Walter, Rudolf Hübler, Berlin Printed in Germany

Preface

This dictionary of obstetrics and gynecology is devoted to a subject in the field of clinical medicine, the development of which is characterized by the fact that the involvement of related specialities is becoming increasingly important for everyday practice: gynecology nowadays includes aspects of preventive medicine and counselling, and it increasingly attracts contributions from the fields of psychosomatic, sexual, and reproductive medicine and their basic theoretical sciences, and also from the basic clinical-diagnostic and theoretical specialities. Obstetrics today means the integration of prenatal and perinatal medicine and also neonatology. The wide range of headwords selected for this reference book does justice to this widened scope and field of activity in obstetrics and gynecology, and it is hoped that this will also make a contribution towards interdisciplinary understanding and cooperation. Given the complex interrelationships and the rapid changes which are constantly taking place in present day medical knowledge, a project such as this can be achieved only as the result of collaboration between a great number of specialists from many different scientific disciplines. The final editing, however, lay in the hands of the Pschyrembel editorial staff, whose constant endeavor it has been to give due consideration to the latest developments in the scientific discussion, and who therefore bear sole editorial responsibility for the contents. The original German version of this dictionary developed as a supplement to and extension of the "Pschyrembel Klinisches Wörterbuch", a medical reference book which has been widely used in numerous editions for almost a century in German-speaking countries. It was edited from 1932 to 1982 by Professor Willibald Pschyrembel, whose name it still bears. This English version is primarily to be understood as the translation of a reference book which has its origins in the German scientific tradition. Nevertheless, also aspects specific to English-speaking countries have been included. The Pschyrembel dictionaries are kept up-to-date and relevant to everyday practice in German-speaking countries through the active involvement of their scientific readers in adding to and extending their contents. The publishers and editors would therefore also welcome comments and suggestions from the readers of this version, which could then be included in a future new edition. - Preprinted forms for this are to be found at the end of the book. Berlin, July 1988

The Publishers

Journal of Perinatal Medicine Founded by Erich Z. Saling Editor-in-Chief: Joachim W. Dudenhausen, Zurich Editors: Roberto Caldeyro-Barcia, Montevideo; L. Stanley James, New York; Erich Z. Saling, Berlin Associate Editors: Günter Scholtes, Berlin; Roy H. Petrie, St. Louis The Journal of Perinatal Medicine is a truly international forum covering the whole field of perinatal medicine. The issues include invited review articles providing a coverage of theoretical and practical points of view in a particular field, original contributions reporting on new results, particularly from the clinical and experimental areas, technical notes describing the characteristics of new instruments of methodological improvements, short communications and letters to the Editors. All contributions submitted for publication are critically reviewed by at least two renowned experts in the field in order to ensure constant high quality of the journal. Published bimonthly; approx. 500 pages per volume. ISSN 0300-5577 1988: Volume 16 (6 issues) Subscription price for Volume 16 for the USA and Canada US $175.00 for all other countries DM 360,-

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Contributors and Consultants

The following is a list of those who were involved in the revision of texts for this edition in collaboration with the dictionary editors of the publishing house. Prof. Dr. med. Leonore Ballowitz Havelmatensteig 12 D-1000 Berlin 22

Kaiserin-Auguste-Viktoria-Haus Heubnerweg 6 D-1000 Berlin 19

Dr. med. Hans-Jürgen Christen Pediatric Hospital of the University Humboldtallee 38 D-3400 Göttingen

Dr. med. Martin Lang Medicines Institute of the Federal Health Authority Seestr. 10 D-1000 Berlin 65

Prof. Dr. med. Gisela Dallenbach-Hellweg Institute of Pathology A2,2 D-6800 Mannheim 1 Prof. Dr. med. Gerhard Döring Seeleite 9 D-8031 Seefeld 2

Priv.-Doz. Dr. med. Dipl.-Psych. Rolf Meermann Medical Director of the Psychomatic Clinic Bombergallee 10 D-3280 Bad Pyrmont

Stefan Exner, Physician Schildhornstr. 72 D-1000 Berlin 41

Dr. med. Heinzpeter Moecke Anesthetics Department General Hospital Altona Paul-Ehrlich-Straße 1 D-2000 Hamburg 50

Prof. Dr. med. Ingeborg Falck Max-Bürger Hospitals of Berlin-Charlottenburg Sophie-Charlotten-Straße 115 D-1000 Berlin 19

Prof. Dr. med. Konrad Morgenroth Institute of Pathology of Bochum University Univ. Chair II Universitätsstraße 15, Gebäude ΜΑ D-4630 Bochum-Querenburg

Prof. Dr. med. Volker Faust Regional Psychiatric Hospital Weissenau Dept. Psychiatry I of Ulm University D-7980 Ravensburg-Weissenau

Prof. Dr. med. Diether Neubert Institute for Toxicology and Embryopharmacology of the FU Berlin Garystraße 5 D-1000 Berlin 33

Prof. Dr. med. Erwin J. Haeberle Institute for Advanced Study of Human Sexuality and San Francisco State University 1100 Gough S t Apt No. 7-C San Francisco, CA 94109, USA

Prof. Dr. med. Detlef Petzoldt University Skin Clinic Vosstraße 2 D-6900 Heidelberg

Dr. med. Hans-Nikolaus Herden Senior consultant of the Anesthetics Department General Hospital Altona Paul-Ehrlich-Straße 1 D-2000 Hamburg 50

Priv.-Doz. Dr. med. Eckhard Petri City Hospitals, Academic Teaching Hospital of the Johannes-GutenbergUniversity, Mainz Dr.-Ottmar-Kohler-Straße 2 D-6580 Idar-Oberstein

Prof. Dr. med. Joachim Hüter Senior consultant of the Hospital for Women City Hospital Weinberg 1 D-3200 Hildesheim

Prof. Dr. Dipl.-Psych. Hans Peter Rosemeier Institute for Medical Psychology Faculty of Basic Medicine of the FU Berlin Habelschwerdter Allee 45 D-1000 Berlin 33

Prof. Dr. med. Jürgen Kunze Pediatric Hospital of the FU Berlin and Institute for Human Genetics

Dr. med. Hiltrudis Schütte Albert-Schweitzer-Hospital D-3410 Northeim VII

Prof. Dr. med. Jürgen Spona 1st University Hospital for Women Spitalgasse 23 A-1090 Vienna Prof. Dr. med. Manfred Stauber Gynecology Clinic and Polyclinic of the Charlottenburg Hospital of the FU Berlin Pulsstraße 4-14 D-1000 Berlin 19 Prof. Dr. sc. med. Johannes Staudt Institute of Anatomy of the Humboldt-University Medical Faculty (Charite) Philippstraße 12 DDR-1040 Berlin Dr. med. Peter Voeltz Anesthetics Department

VIII

General Hospital Altona Paul-Ehrlich-Straße 1 D-2000 Hamburg 50 Dr. Dr. med. Helmut Weyers f D-2160 Stade Prof. Dr. med. Dr. jur. Reinhard Wille Sexual Medicine Research- and Counselling-Center Hospitalstraße 17-19 D-2300 Kiel Dr. rer. pol. Angela Zink Director of the Unit for Social Medicine and Epidemiology GSD Gesellschaft für Systemforschung und Dienstleistungen im Gesundheitswesen mbH Stauffenbergstraße 13-14 D-1000 Berlin 30

Translation work

Η. Frank Andersen, MD Assistant Professor Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology University of Michigan Medical Center 1500 East Medical Center Drive USA-Ann Arbor, Michigan, 48109 P. Bye, MD, MB Chir, MRCS, LRCP, Dip Pharm Med RCP, DCH Schering Health Care Ltd. The Brow Burgess Hill GB-West Sussex RH15 9NE Deborah Doughten, MD Brandenburgische Straße 24 D-1000 Berlin 31 Kathleen R. Dyer, BA, ALA, SRN, SRCN Schering Health Care Ltd. The Brow Burgess Hill GB-West Sussex RH15 9NE Michael Hopkins, MD Assistant Professor Division of Gynecologic Oncology University of Michigan Medical Center 1500 East Medical Center Drive USA-Ann Arbor, Michigan, 48109

Edltors

Regina Engst, Librarian Helmut Hildebrandt, Μ Α . Karin Schick, Physician Helmut Schwäbl Ί" Thomas Spitzer Andreas Weimann, Physician Dr. med. Christoph Zink

Dr. med. Ursula Rahe-Badenhoop Mollstraße 39 D-6800 Mannheim 1 John F. Randolph, MD Assistant Professor Division of Reproductive Endocrinology University of Michigan Medical Center 1500 East Medical Center Drive USA-Ann Arbor, Michigan, 48109 Dietrich W. Roloff, MD Professor of Pediatrics Director of Newborn Services and Pediatric Pulmonary Medicine University of Michigan, Medical Center 1500 East Medical Center Drive USA-Ann Arbor, Michigan, 48109 Mary Ann C. Roloff, MD Department of Pediatrics University of Michigan Medical Center 1500 East Medical Center Drive USA-Ann Arbor, Michigan, 48109 Bernd Κ. Wittmann, MD, FRCS (C) Associate Professor; Director Department of Diagnostic Ultrasound Grace Hospital 4490 Oak Street CDN-Vancouver, B. C. Canada V6H 3V5

Explanatory Notes

1. Alphabetical order The entries are arranged in strict alphabetical order according to the sequence of each letter, with spaces between words and punctuation marks being ignored. Plural forms are an exception here (nervus pelvicus comes before nervi spinales). In addition the "'s" for eponyms and also Greek letters and any figures have been ignored. Proper names which begin with "Mc" are treated as though they began with "mac". 2. Etymological data An etymological explanation is given in brackets after headwords of Greek or Latin origin. As a rule this consists of three elements: language of origin, original word (transcribed in the case of Greek terms) and the English meaning. The original word is not listed again separately if it is identical to the headword; the English meaning is not given if it is the same as the explanation for the headword.

fore be found in their appropriate alphabetical place in the dictionary. General abbreviations are given in the Abbreviations list (see p. XI). 5. Cross-references Consultation of the dictionary has been made easier through the use of a large number of cross-references. These references (in combination with "see", "see also", and "cf") are located in the suitable context; in case of a more general reference it is to be found at the end of the entry. In the continuous text references are marked with a (*) behind the word which is relevant for the alphabetical assignment. 6. Sources for the Tables and Illustrations Details of the sources for the tables and illustrations are to be found in a separate list at the end of the book, arranged in order of the corresponding headwords.

3. Biographical data

7. Special Symbols

If proper names form a constituent part of a headword, biographical data are added in brackets, arranged as follows: first name, surname, speciality, main place of work, date of birth and possibly of death.

Under the collective anatomical terms Arteria, Musculus, Nervus, and Vena special symbols have been used to indicate the anatomical relationships: For arteries, veins, and nerves * indicates origin, — > course, —> branches. For muscles and ligaments < — > comes between the origin and attachment.

4. Abbreviations Specific medical abbreviations have been included in the list of headwords and will there-

X

Abbreviations

Commonly used medical abbreviations not included in the following list are to be found as headword entries. Cf. Explanatory Notes, p. X (Abbreviations, Special Symbols). a. aa. abbr. appr.

artery arteries abbreviation appropriate

INN(L)

biol. BW

biological(ly) body weight

I.V.

International Nonproprietary Name (Latin) international units International Union of Pure and Applied Chemistry intravenous(ly)

c. ca. CAS-No.

kg

kilograms

cf. cm CNS CSF

circa carcinoma Chemical Abstracts Service Number compare centimeters central nervous system cerebrospinal fluid

Lat ligligg·

Latin ligament ligaments

dim.

diminutive

m. mill. min. mm mm.

muscle million(s) minute millimeters muscles

e.g. embryol. esp. etc.

for example embryology, -ological especially and so on

n. nm nn.

nerve nanometers nerves

Fig. Fr.

figure French

obst occ.

obstetrics, obstetrical occacional(ly)

g Ger. GI Gr. gyn.

grams German gastrointestinal Greek gynecology, -ological

pathol. ped. pharmac. physiol.

pathology, -ological pediatrics pharmacy, pharmacological physiology, -ological

hemat hist hr.

hematology, -ological histology, -ological hour(s)

r. rr.

ramus (branch) rami (branches)

sec. syn.

second synonym

i.e. I.M. immun. incl. ind. INN(E)

that is intramuscular(ly) immunology, -ological inclusive(ly) indication International Nonproprietary Name (English)

Tab.

Table

v. w. vol.

vein veins volume

wk.

week

IU IUPAC

XI

New Developments in Biosciences Volume 1:

LH-RH and its Analogues Fertility and Antifertility Aspects Edited by Manfred Schmidt-Gollwitzert Co-Editor: Rosemarie Schley 1985.17 χ 24 cm. X, 357 pages. With 174 illustrations and 54 tables. Paperback DM 9 8 - ISBN 311010055 X

Volume 2:

A Modern Approach to the Perimenopausal Years Edited by Robert Greenblatt Co-Editor: Renate Heithecker 1986.17 χ 24 cm. VI, 256 pages. With 62 illustrations and 44 tables. Paperback DM 98,- ISBN 311010937 9

Volume 3:

Antiandrogen-estrogen therapy in signs of androgenization Editor: Adolf E. Schindler 1987.17 χ 24 cm. 244 pages. With 101 illustrations and 59 tables. Paperback DM 9 8 - ISBN 311011225 6

Volume 4:

Endocrine Management of Prostatic Cancer Editor: Herbert Klosterhalfen 1988.17 χ 24 cm. VI, 138 pages. With 45 illustrations and numerous tables. Paperback DM 4 8 - ISBN 3110115131

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A

abdomen,

acute

(Lat. a b d o m e n

belly):

clinical term for an acute illness, often lifethreatening, in the abdominal cavity. An acute abdomen requires rapid diagnostic decisions and usually surgical treatment. Typical signs and symptoms: sudden onset of pain, change in peristalsis, vomiting, abnormal stools, malaise, signs of bleeding, possibly fever. Causes: (gyn.) adnexal torsion (e.g. ovarian tumor), ruptured tubo-ovarian abscess, severe pelvoperitonitis (incl. iatrogenic after intrauterine procedures); (obst.) extrauterine pregnancy, ruptured uterus. Diagnosis: 1. if a gynecological diagnosis is likely: culdocentesis* to rule out extrauterine pregnancy*, pelvioscopy*; 2. if etiology is not clear: abdominal radiography, laparoscopy, or laparotomy. Differential diagnosis: abdominal (e.g. intestinal obstruction, perforated viscus) and extraabdominal diseases (e.g. myocardial infarction, pneumonia). Caveat: immediate hospital admission; no opiates until diagnosis and indication for surgery are established; no enteral feedings ! Cf. peritoni tis. abdominal complaints, functional:

dif-

ferentiation of: 1. functional upper abdominal complaints (pressure, fullness, aerophagia); 2. functional lower abdominal complaints (pain, diarrhea, constipation, mucoid stools). According to psychoanalytic theory prevailing in German psychosomatic medicine various personality types correlate with these (upper abdominal complaints: depressive or neurotic traits with phobias and compulsions due to oral dependency in early childhood; lower abdominal complaints: perfectionist, compulsive personalities showing conflicts between retention and yielding). abdominal guarding: localized t e n s i o n of

abdominal muscles either diffuse or by reflex in the presence of peritoneal irritation or peritonitis*. abdominal pressure: c o m p r e s s i o n of t h e

abdominal contents by the abdominal muscles while the diaphragm is fixed (inspiration against the closed glottis) to aid in expelling contents of abdominal hollow organs (intestines, bladder, uterus). aberrations, chromosomal (Lat. a b e r r a r e

to deviate): deviations from the normal chromosome count (44 autosomes* and 2 sex* chromosomes) or structural deviations of individual chromosomes; they are probably often due to a disorder of meiosis*, but may also occur Elfter disorders in the cleavage divisions of the zygote. If separation and distribution of a pair of chromosomes do not take place (non*-disjunc-

tion) during the reduction division, then both chromosomes get into one of the gametes but none in the other. Through fertilization a blastocyst develops, the cells of which are either hyperdiploid (trisomic) or hypodiploid (monosomic). These aberrant cells are usually not viable (see lethal factor), but may also become mature. As a result the set of chromosomes which is increased or decreased by one chromosome passes over into all cells of the newly developed organism. A chromosomal aberration of the sex chromosomes is found for example in Klinefelter's* syndrome and in gonadal dysgenesis*, as an autosomal aberration in Down's* syndrome. The risk of chromosomal aberrations increases with the age of the parents (see Table); cf. isochromosomes. Chromosomal aberrations F r e q u e n c y of c h r o m o s o m a l a b e r r a t i o n s in relation to the a g e of the parents Mother 35-40 35-40 41 - 4 3 41 - 4 3 >43

Father yrs. yrs. yrs. yrs. yrs.

35-40 >41 41 >43

Risk yrs. 1-2% yrs. 2-3% yrs. 4% yrs. >5% yrs. up to 9%

aberrations, chromosomal, radiation-in-

duced: changes induced in the chromosomes* by ionizing radiation (chromosome mutations, usually chromosome breaks) in somatic cells or in gametes; can be clearly demonstrated in peripheral blood cells in humans after high doses of radiation (high therapeutic doses of radiation, atom bomb victims) (see Fig. next page). Exogenously induced chromosome mutations are rarely transmitted by heredity, since they have a lethal action during the prenatal period* in the majority of cases. Cf. radiation damage, genetic. ABO-erythroblastosis: s e e

erythroblasto-

sis fetalis, erythroblastosis neonatorum. ABO-incompatibility: blood group incompatibility in the ABO-system; e.g. donor has blood group B, recipient has group 0; infant has group A, mother group 0 in erythroblastosis* neonatorum. Affected are almost exclusively mature neonates, because A and Β receptors on the red cells mature only late in gestation and early extrauterine life. Maternal A- or B-immune antibodies may also enter the blood of prematures, but they only slightly af1

abortifacients of a live birth*; abortions are not required to be registered. Internationally, a time limit (before the completed 20th or 28th week) is also used for definition. See also stillbirth, intrauterine fetal death.

Radiation-induced chromosomal aberrations: Diploid set of chromosomes of a lymphocyte with various structural changes of the chromosomes (arrows)

Abortion: Clinical manifestations

Radiation-induced chromosomal aberrations: Effects of ionizing radiation on the DNA; a: single-strand break; b: double-strand break; c: base damage; A, T, C, G: corresponding purine and pyrimidine bases of the DNA double helix feet the fetal red cells which are only minimally A/B characterized yet. abortifacients: substances which induce uterine contractions, used to induce an abortion*, include ergotamines, quinine (undoubtedly cause damage to the fetus and the mother!) and prostaglandins*; cf. sulprostohe. abortion (Lat. aboriri to go away, to perish): miscarriage; premature termination of a pregnancy by the expulsion of a fetus of less than 35 cm length with the absence of all signs

abortion, cervical: an abortion in which the expulsion of the uterine contents is prevented by a tight cervical os (e.g. because of scars); rare. See dystocia, cervical. abortion, complete: an abortion in which fetus and placenta are expelled entirely, usually an early abortion (up to the 16th week). It should be followed by a curettage until the 20th week (see curettage, postpartum). Cf. abortion, incomplete. abortion, criminal: any illegal termination of pregnancy*. abortion, early: an abortion before the (14th or) 16th week; frequently as incomplete* abortion. abortion, febrile: manifestations: 1. uncomplicated f.a. (localized endometrial infection); 2. complicated f.a. (adnexa involved); 3. septic abortion: generalized infection and risk of endotoxic shock; course as in sepsis. abortion, habitual: habitual abortion is present if at least 3 consecutive pregnancies resulted in a spontaneous abortion*. abortion, incomplete: usually occurs as late abortion* (after the 16th week); the expulsion of the fetus and placenta resembles a birth with rupture of the membranes and labor-like pain. Because placental parts often remain in utero, a postpartum curettage* is necessary. See abortion, complete. abortion, induced: an intentional termination of pregnancy*.

acn6 excori6e des jeunes filles abortion, induction of: the pharmacologically induced termination of pregnancy*, e.g. with prostaglandins*. abortion, inevitable: the unavoidable, beginning abortion; bleeding and/or contractions with early cervical dilatation. abortion, infected: an abortion* with inflammation of uterus or adnexa. abortion, late: an abortion* after the (14th or) 16th week of gestation; usually proceeds as incomplete abortion*; if the fetus lives, it is a premature delivery*. abortion, missed: an abortion in which the product of conception despite prolonged bleeding is not spontaneously expelled; medical assistance is required. Retention may last weeks to months and lead to the dead*-fetus syndrome. Cf. intrauterine fetal death. abortion, septic: the most severe manifestation of febrile abortion*; cf. abortion, infected. abortion, spontaneous: abortion* without exogenous causes, an unintended abortion. Causes: 1. ovular (see also ovum, blighted); 2. maternal (gynecological, endocrine disorders, severe general illnesses, psychic trauma, individual predisposition; see also habitual abortion); 3. immunological (e.g. blood group incompatibility). Types: see abortion, Fig. abortion, therapeutic: see pregnancy, termination of. abortion, threatened: a potential abortion with mild hemorrhage or contractions or both with a closed cervix. Cf. tocolytics. abortion, tubal: see pregnancy, extrauterine; pregnancy, tubal. abortion, uncomplicated: an abortion* without inflammatory involvement of the adjoining organs. abruptio placentae (Lat. abrumpere to tear away): partial or complete separation of the placenta from its contact site before birth. It occurs either in late pregnancy or during birth (usually during dilatation) leading to hemorrhage from maternal or sometimes fetal vessels at the contact surface and thus to the formation of a retroplacental hematoma*. Causes: in most cases (50-70%) undetermined, in the remainder frequently due to pre*-eclampsia. Signs and symptoms: sudden lower abdominal pain, malaise, anxiety, vertigo/feeling faint, shortness of breath; cessation of fetal movements; often only minor external bleeding; sometimes shock, coagulopathy; Prognosis: even detachment of a quarter of the placental surface can lead to oxygen deficiency and intrauterine* fetal death; with more than half the placenta detached there may be life-threatening blood losses of mother and fetus. Differential diagnosis: placenta* praevia, uterine rupture*. Cf. Couvelaire uterus. abscess, ovarian (Lat. ab away; cedere, cessus to go, gone): purulent changes in the ovarian tissue from a hematogenous or direct (e.g. ascending or contact) infection, e.g. in salpingitis, pelvoperitonitis, appendicitis. abscess, retromammary: an abscess located behind the breast gland between the su-

perficial and deep fascia layers. Cf. mastitis, interstitial. abscess, tubo-ovarian: an abscess involving the ovary and tube originating from an ovarian abscess* or a pyosalpinx*. It is due to purulent penetration of the separating tissue layers or by the infection of a follicle and adhesions between pyosalpinx and ovary. acceleration: 1. acceleration of t h e developmental velocity with an increase in the final size in both sexes. Acceleration of growth with a mean increase in length of 5-10 cm and usually associated with the earlier occurrence of puberty* by 1-2 years (acceleration of development) has been observed in industrialized and agrarian countries since the turn of the century. Among the speculative explanations is that of the "urbanization trauma" in which urban life increases the autonomic, endocrine, and cerebral reactivity of children of various social strata. 2. in cardiotocography*: the increase in fetal heart rate related to contractions (periodic acceleration) or fetal movements. The clinical significance is not entirely clear, but it is now generally thought to be a prognostically favorable sign. acetylcholinesterase test: colorimetric determination of acetylcholinesterase in amniotic fluid obtained by amniocentesis (usually between the 14th and 18th week of pregnancy). Ind.: suspected fetal anencephaly or spina bifida (cf. dysraphic syndromes). This test is more sensitive t h a n the more usual determination of t h e alphafetoprotein*, since it is not affected by minimal amounts of maternal blood in the amniotic fluid (false positive results). Mean activity in normal pregnancy: 3 nmol min · ml acidosis, intrauterine primary metabolic: a pathological condition of the fetus as defined by Saling by fetal microblood sampling (cf. fetal blood analysis). Definition: predominantly metabolic acidosis, i.e. even after equilibration a persistent low pH. Cause: decreased 0 2 -supply before and during birth (in utero), e.g. due to placental insufficiency*, umbilical* cord complications, erratic administration of labor medications, inferior*-vena-cava syndrome, prolonged labor. acne (Gr. acme tip, peak): various diseases of the sebaceous follicles characterized by abnormal secretion, cornification with subsequent inflammation and scar formation, usually as acne* vulgaris; see also acne conglobata. acne conglobata (Lat. conglobare to conglomerate): the most severe form of acne with giant comedones (epidermal cysts filled with masses of cornified cells), fistulous comedones (interconnected by tracts with several openings), abscesses, and keloid-like scars with tissue bridges. Location: face, trunk, buttocks, genital area, extremities. Men are more often affected than women. Acne conglobata may be seen in women with androgen-producing tumors. acn6 βχοοπόθ des jeunes filles (Fr. excorie chafed; jeunes filles young girls): factitious acne; compulsive squeezing of small acne 3

acne neonatorum eruptions with finger nails causing crusted erosions and pigmented scars. acne neonatorum (Lat. neonatus newborn): comedones and pustulous papules in the first two months of life; spontaneous regression within a few months. Cause: sensitivity of the sebaceous glands to maternal androgens. acne vulgaris (Lat. vulgaris ordinary): between the onset of puberty and the 25th year seborrhea in the skin areas rich in sebaceous glands (face, neck, chest, back) and increased keratinization lead to a plugging of the follicles, formation of blackheads, and the typical acne eruptions. There is usually spontaneous

Acne vulgaris healing in early adulthood. Etiology: among the many factors are genetic disposition (probably autosomal dominant with variable expression), seborrhea, certain bacteria (Propionebacterium acnes, P. granulosum, and P. parvum), hormonal influences, disturbances of cornification, increased follicular reactivity to noxious chemicals (vaseline, tar products, steroids), and an altered immune reaction. Androgens stimulate the production of sebum and thus promote acne in predisposed individEtiologic factors in acne vulgaris include: 1. Hormones: predominance of androgens; therapeutic use of testosterone, anabolic steroids, glucocorticoids. 2. Bacterial secondary infections. 3. CNS factors. 4. Gl disturbances. 5. Faulty nutrition. 6. Bromine, iodine, chlorine, tar, oils, vitamin D, isoniazide. 7. Heredity. 8. Foci. uals. Therapy: external treatment with skin cleansers, antiseborrheics; sometimes estrogen or antiandrogen therapy in the course of hormonal contraception*; keratolytics; also antibiotics (tetracycline) and antiphlogistics. acute abdomen: see abdomen, acute, aciclovir (INN-Ε): acyclovirum (INN-L), 9 -[(2-hydroxyethoxy)methyl] guanine (IUPAC); CAS-No. 59277-89-3; C 8 H n N 5 0 3 (see Fig.); molecular weight 225.22. Use: virostatic agent for infections, esp. with herpes or varicella-zoster viruses.

Ο

Ν —CHj— Ο — (CHj)2—OH Aciclovir (INN) adaptation, maternal: the physiological adaptation processes of the maternal organism during pregnancy. 1. organic changes (usually hormonally mediated): genitalia: increased size of the uterus (see fundus height) and thus of abdominal girth; further changes are considered probable signs of pregnancy*; breasts: increased size; water/electrolytes: retention of sodium and water, possible edema formation (differential diagnosis: pre-eclampsia), in part accounting for the weight gain; blood: increased plasma and red cell volume (see also pregnancy, anemia of), leukocytosis, hypercoagulability; circulatory: increased cardiac output, relatively constant blood pressure, impaired venous return (see inferior-vena-cava syndrome) with increased thrombotic tendency (see also varicose veins of pregnancy); lung: increased minute volume, dyspnea of pregnancy; gastrointestinal: increased salivation, acid burn, atonic constipation (loss of tone due to progesterone effect); kidneys/urinary tract: increased glomerular filtration, increased susceptibility to urinary tract infections (see also pregnancy, bacteriuria of); decreased bladder capacity; endocrine: increased basal metabolism (reversible thyroid hyperplasia), increased production of Cortisol and aldosterone; skin: stretch* marks, chloasma*; skeleton: pelvic relaxation*, lordosis. 2. psychological changes: mood swings (esp. in the first trimester and in Primigravidae), adjustment to the new family situation (e.g. role conflicts in working couples); cf. psychosis of pregnancy. adaptation, neonatal: the transition from intrauterine to extrauterine life with particular reference to the adaptation of circulation* (see Fig.) and respiration immediately after birth (see also lung development, fetal). For the evaluation of these vital functions: see assessment, neonatal. In the later neonatal period the gradual adaptation of other immature functions occurs, e.g. liver, digestion, thermoregulation, immune response. adenoacanthoma (Gr. aden gland): adenocarcinoma of the endometrium* with islands of benign squamous epithelium due to the polyvalent differentiating potential of the glandular epithelium; clinically important is the histological differentiation from an adenosquamous carcinoma of like origin with immature metaplasia of the squamous epithelium, because of the much better prognosis of adenoacanthoma. adenocystoma: see cystadenoma. adenofibroma: a benign mixed tumor consisting of benign epithelial (glandular) and mesenchymal (fibromatous) components; densely intermixed. The glandular epithelium may show varying degrees of differentiation

adolescent menses

from brain and upper extremities

to brain and upper extremities

ductus arteriosus

aorta

placenta

I reduced c m oxygenated

Neonatal adaptation: Change of fetal circulation with the onset of pulmonary respiration

^S&r

ff.u-ψ-

• r150 (> 160) bpm; bradycardia: < 120 bpm. baseline transition: see zero line transition. Baudelocque's

diameter

(Jean-Louis

Baudelocque, gynecologist, Paris, 1745-1810): conjugate externa; see measurements, pelvic. BBT: abbr. for basal body* temperature, behavior, sexual: see sexual behavior.

Berardinelli's s y n d r o m e (W. B e r a r d i n e l l i ,

endocrinologist, Rio de Janeiro): a rare congenital hormonal-metabolic disease with hyperactivity of the hypophysis. Etiology: unknown, increased familial incidence. Signs: infantile gigantism with athletic constitution, hypergenitalism, no secondary sexual characteristics, lipodystrophy, organomegaly (heart, liver, spleen), accelerated bone development; manifestation in early childhood. Diagnosis: increased urinary 17-ketosteroid excretion, hyperlipemia, hyperproteinemia, impaired glucose utilization. Cf. leprechaunism. Bier's suction cup (August K. G. Bier, surgeon, Berlin 1861-1949): see vacuum extractor. bilirubin: breakdown product of heme, colored yellow-brown-red. Indirect or unconjugated bilirubin is not bound to glucuronic acid and is bound in plasma to albumin, normal value 0.1-0.2 mg/100 ml. As a lipophilic substance it may pass the epithelial barrier, but passes the blood-brain barrier only in the neonate (risk for kernicterus*). In liver, conjugation with glucuronic acid (conjugated, direct bilirubin) renders it water-soluble. Excretion occurs in bile, to a smaller extent through the kidneys (increased in biliary obstruction). In the urine there is only conjugated bilirubin. Cf. hyperbilirubinemia, neonatal; spectrophotometry, amniotic-fluid. Billings' ovulation m e t h o d : s y n . c e r v i c a l

mucus method; the observation by the woman of her intermenstrual cervical mucous secretions for the determination of the fertile and infertile days in the menstrual* cycle, e.g. for purposes of contraception. Coitus needs to be avoided only on those days where discharge of liquid cervical mucus* from the vagina is observed by the woman. According to Billings any unprotected intercourse is to be avoided

birth control from the begin of the mucus secretion until the evening of the 4th day after its maximum. Advantage: as in all methods of natural contraception*, there are no physical side effects. Disadvantage: low reliability (Pearl index: 15-25). biopsy (Gr. bios life; opsis vision): the removal of a piece of tissue (tumor) for histological examination. biopsy, endometrial: with a special curette, usually without dilatation or anesthesia, strips of endometrial mucosa from the anterior and posterior walls of the uterus can be obtained for histological examination and evaluation of the current influence of estrogens and gestagens on the endometrium*. Indications: suspected endometrial disturbances (functional sterility*), uninterpretable baseline temperature records, suspected uterine amenorrhea*, and to check the responsiveness of the endometrium to exogenous hormone administration. biopsy, ovarian: a biopsy from the ovary* (as punch biopsy under laparoscopic view or as wedge excision during laparotomy), e.g. for the histological clarification of suspected ovarian hypoplasia. birth: the process of expelling the fetus from the mother's body by labor (see contractions); as a rule the onset of labor* is preceded by the signs of birth. The course of a normal birth in occipital presentation: initiation of the first stage of labor (dilatation* period) with distension of the cervix (distraction), and bulging of the membranes until complete dilatation of the os, marking the end of the first stage. After the rupture* of the membranes

the second stage (expulsion phase) begins: 1. entry: the sagittal suture is transverse upon entry into the pelvic inlet; 2. passage: flexion (occiput as presenting* part), descent, and rotation of the head constitute the path of least resistance; 3. exit: beginning deflexion of the head (posterior fontanel is left anterior, sagittal suture oblique), then pronounced deflexion (posterior fontanel is anterior, sagittal suture median); the birth of the trunk follows elfter reverse rotation during one of the next contractions. Subsequently, the third stage until the placenta is delivered (during which time the cord* is clamped; see also adaptation, neonatal), and then the postpartum* period. Advances of medicine and the associated reduction in infant* mortality have moved births into the hospital. However, in addition to demands for safety, the emotional content of the experience for all involved (mother, father, child) has become important again. Proposals toward this end relate to childbirth preparation (see also Read's method), the birth environment, e.g. involvement of the father (Bradley), "conscious" birth (Lamaze), and "gentle" birth (Leboyer). Recently, ambulatory deliveries in birthing centres (early discharge 4-24 hours after an uncomplicated birth) have been introduced as an organizational step between hospital and home deliveries. Cf. birth, high-risk; delivery, operative. birth canal: l.bony canal: the lesser pelvis (see planes, pelvic); 2. soft canal: a) lower uterine segment and cervix; b) attached tube of soft parts (vagina, vulva, pelvic floor muscles). birth control: see contraception, family planning; cf. population control.

Birth: Normal delivery in occiput posterior presentation: 1: entry into the pelvis (descent); 2: passage through the pelvis (engagement); 3: exit from the birth canal (internal rotation); 4: exit completed, delivery of the head (extension); 5: external head rotation, delivery of the shoulder; 6: external head rotation completed, delivery of the posterior shoulder 25

birth, high-risk birth, high-risk: a b i r t h w i t h i n d i c a t i o n s of

an increased risk for mother and/or fetus; 1. after a high-risk pregnancy*; 2. the risk signs occur only during delivery, e.g. meconium-stained amniotic fluid, abnormal fetal heart-rate, maternal hypertension, bleeding, prolonged labor. Cf. newborn, high-risk; distress, fetal. birth index: s e e n a t a l i t y , birth, induction of: s e e labor, i n d u c t i o n of. birthing center: s e e b i r t h ,

birth, live: a live birth is defined regardless of length or weight of the fetus or the duration of the pregnancy, if after complete expulsion from the birth canal there has been a heart beat, natural respirations have taken place, or the umbilical cord has pulsated. The World Health Organization recommends to include voluntary muscle contractions as an additional sign of life. The definition of a live birth is not uniform in different countries. See also stillbirth; abortion; infant, premature. birth palsy: a p a r a l y s i s o r i g i n a t i n g d u r i n g

the birth process, esp. 1. facial palsy which almost always is caused by pressure of a blade

Birth palsy: Facial palsy; note the asymmetrical nasolabial folds

on the lower branch of the facial nerve during forceps* extraction. The prognosis is good if the palsy is peripheral and not central (intracranial hemorrhage!); 2. brachial plexus* palsy, caused by pressure or traction on the brachial plexus (e.g. in shoulder dystocia). birth, precipitate: a v e r y r a p i d d e l i v e r y , birth rate: s e e n a t a l i t y , birth, readiness for: s e e r e a d i n e s s f o r

birth.

birth, signs of: t h e p r o d r o m e s of c h i l d b i r t h :

"dropping" of the gravid uterus (in primiparae) about 3 weeks before the onset of labor* (see also fundus height), irregular contractions, displacement of the long axis of the cervix toward the pelvic axis, cervical ripening*. birth trauma: a n y i m p a i r m e n t i n t h e h e a l t h

26

state of a newborn* which is caused by the birth process. The most important are: 1. hemorrhages: e.g. intracranial, peritoneal, adrenal, cf. cephalhematoma; 2. skin and soft tissue injuries: e.g. subcutaneous fat* necrosis, birth* palsy; 3. bone injuries: fractures of clavicle, humerus, femur; the rate fractures of skull and vertebrae have a much poorer prognosis. Cf. birth. birth weight: the mean birth weight at term in boys is 3400 g, in girls 3200 g; much physiological variability (see also newborn); cf. weight change in infancy. bisexuality: the term denotes sexual activity, excitability, and orientation toward men and women without specific preference for one sex. Until the end of puberty bisexual behavior is frequently observed (psychoanalysis assumes an a priori bisexuality of humans). In adults bisexuality is the exception in comparison to predominantly heterosexual or predominantly homosexual behavior. Bishop score: s e e c e r v i x s c o r e , bladder drainage: t h e m e c h a n i c a l d r a i n a g e

of urine in persistent or temporary disorders of micturition; frequently employed postoperatively in operative gynecology, esp. after plastic procedures of the vagina and operations for the treatment of urinary incontinence*. Types: transurethral bladder drainage with a catheter is the method with the highest risk of infection because organisms from the contaminated vulva/perineum ascend along the urethra into the bladder (after 48 hours there is bacteriuria in 100% of the cases!). Suprapubic bladder drainage decreases this risk considerably and should be used when a longer-lasting drainage is necessary and in cases where intermittent catheterization (which is associated with the lowest infectious risk) is not feasible. The sterile placement of the drainage systems is as important as the correct use of closed urine collection devices. 75% of infections a c q u i r e d in hospital by g y n e c o l o g i c a l and obstetric in-patients a r e urinary tract infections! bladder, irritable: a p o o r l y d e f i n e d t e r m f o r

a chronic irritation of the lower urinary tract; occurs esp. in women. Symptoms: dysuria, urgency, frequency, suprapubic pain, and diffuse complaints when sitting. Frequently there is a marked discrepancy between the severe complaints of the patients and the objective findings. Differential diagnosis: infections* of uriIn e a c h c a s e the irritable b l a d d e r is a s y m p t o m , not a d i a g n o s i s !

nary tract, alterations in the lower urinary tract, diseases of adjacent pelvic organs, CNS and spinal cord diseases (e.g. multiple sclerosis). Common causes: disturbances of the vegetative or endocrine systems (neuro-hormo-

bleeding, m i d - c y c l e

nal irritable bladder). Therapy: local and systemic estrogen treatment, alteration of the psychovegetative dysregulation. blastema (Gr. germ): rudimentary protoplasm, indifferent germinal tissue. blastocele (Gr. blastos germ): the fluidfilled cavity of the blastocyst*. blastocyst: (embryol.) collection of cells which develops out of the morula* on about the 4th day after fertilization, forms a blasto-

tions are excluded, a change of the preparation (with higher estrogen content or a multiphasic preparation) is recommended. Cf. follicle, persistent. bleeding, climacteric: irregular, often heavy, menstruation-like bleeding in the climacteric. During premenopause generally a dysfunctional bleeding*, during postmenopause bleedings of organic causes are more common (e.g. carcinoma of the female genital tract). See climacteric; cycle, anovulatory; carcinoma, endometrial; cf. metrorrhagia. bleeding, dysfunctional: bleeding which is caused by hormonal disturbances; more n a r rowly bleeding due to a persistent follicle*. So-called adolescent* menses a t the beginning of the reproductive age and, conversely, climacteric bleeding are also dysfunctional bleedings. The pattern of the bleeding alone does not safely differentiate between dysfunctional and organic hemorrhages.

Blastocyst: Structure on about the 4th day of development of the human embryo; a: embryoblast; b: blastocyst cavity; c: trophoblast

cyst cavity and in which it is possible to distinguish between an external cell layer (trophoblast*) and an internal cell mass (embryoblast*) (Fig.). blastogenesis: (embryol.) first developmental steps which the zygote* passes through up to the commencement of embryogenesis* in the narrower sense (c. 15th day); in the wider sense development of the zygote u p to the first heart beat of the embryo (c. 23rd day); cf. morula, blastocyst, embryoblast. blastomeres (Gr. meros part): (embryol.) cells which develop through cleavage* of the zygote*; they divide without growth and thus become smaller at each division, t h e plasma/ nucleus-ratio shows a shift in favor of the nuclei. blastopathy (Gr. pathos disease): prenatal disease resulting in an intrauterine developmental disorder of the product of conception in the first 2 weeks after conception; as a rule consists of profound malformations, as a result of reorganization of the blastocyst (e.g. cyclopia). bleeding, acyclic: s e e m e t r o r r h a g i a , bleeding, anovulatory: s e e bleeding, w i t h -

bleeding, functional: t h e h o r m o n a l l y r e g -

ulated menstrual bleeding; see menstruation; cf. bleeding, dysfunctional. bleeding, intermenstrual: bleeding which occurs in the course of a menstrual cycle outside of menstruation* (Fig.); see menstruation disorders.

Intermenstrual bleeding is often the first sign of a carcinoma. Therefore all women with intermenstrual bleeding must undergo a very thorough gynecological examination. bleeding,

mid-cycle:

intermenstrual

bleeding* between two menstrual periods ex-

drawal. bleeding, atonic: a hemorrhage from the uterus after delivery due to poor contractility of the uterus. bleeding, breakthrough: a uterine bleeding resembling menstrual flow which occurs with an unchanged level of endogenous and exogenous sex* hormones which, however, is not sufficient for the maintenance of the intact endometrium; weaker bleeding is termed spotting. If breakthrough bleeding occurs while oral contraceptives and drug interac27

bleeding, ovulatory cept premenstrual* and postmenstrual* bleeding (Fig.). A particular form is ovulatory bleeding*; cf. menstruation disorders. bleeding, ovulatory: a form of mid-cycle bleeding* with a small amount of endometrial bleeding at the time of ovulation, often associated with mittelschmerz*; it is the consequence of a more pronounced drop in estrogen.

flew

1.

2.

4.

3.

5.

I

cycle 6.

heavy normal light

il

Ovulatory bleeding (menstrual calendar) bleeding, post-coital: a vaginal bleeding caused by intercourse or vaginal douche; an initial sign in carcinoma of the cervix. bleeding, postmenstrual: bleeding after the actual menstrual bleeding (see menstruation). Causes: 1. hormonal: delayed regression of the corpus* luteum (i.e. premenstrual disorder); 2. organic: e.g. with endometrial carcinoma, polyps, submucous myoma, endometritis, endometriosis interna; also in impaired regeneration of the endometrium (e.g. after repeated curettage and in multiparae). Cf. menstruation disorders.

flow heavy normal light

1.

2.

3.

4.

5.

cycle 6.

I I

I

ί Ill

i

ll

i,l

Postmenstrual bleeding (menstrual calendar) bleeding, premenstrual: bleeding for a few (up to 10) days before the actual menstrual bleeding, usually slight, from the spiral arteries of the endometrium. Cause: usually due to a premenstrual corpus* luteum insufficiency, 1.e. the drop in estrogen and progesterone production occurs too early. Thus, the conditions for nidation are inadequate, and there often is sterility*. With even the slightest suspicion for an organic cause a fractionated curettage should be performed. Cf. menstruation disorders. bleeding, uterine: bleeding from the uterus, including menstruation as a physiological cause. Pathological causes: 1. organic: due to pathologic-anatomical changes (endometrial carcinoma, polyps, endometritis, myoma, etc.); 2.dysfunctional bleeding*: due to hormonal (pituitary-ovarian) disorders. Differential diagnosis: vaginal bleeding from a non-uterine source. 28

bleeding, withdrawal: the onset of uterine bleeding 3-7 days after the discontinuation of the administration of female sex hormones due to shedding of the shrinking endometrium (hormone withdrawal), also in anovulatory cycles; often it does not differ from normal menstruation* in amount or duration. blindness, eclamptic: the loss of vision and all optic function as rare complication of an eclamptic seizure; caused by the generalized vasospasm in the CNS, characteristic for eclampsia*. block, anesthetic: see anesthesia, local, block, lochial: see lochiometra. block, paracervical: the elimination of nerve conduction by the pelvic plexus by injection or infusion (continuous paracervical block) of a local anesthetic into the paracervical tissue. Indications: analgesia during the first stage; when combined with pudendal anesthesia* also during the second stage of birth. Complications: 1. fetal bradycardia and acidosis; 2. maternal allergic and toxic reactions; 3. inhibition of contractions. blood analysis, fetal: see fetal blood analysis. blood-group incompatibility: l . t h e presence of antibodies in the recipient (less often the donor) against components of transfused blood or blood products which may imperil the result of the transfusion and cause incompatibility reactions. 2. the formation of antibodies in the mother by which the fetus or neonate can be harmed (see erythroblastosis fetalis, neonatorum). blood mole: see mole, blood. Bochdalek's hernia (Vincent Bochdalek, anatomist, Prague, 1801-1883): a specific form of congenital diaphragmatic hernia through the left posterolateral gap of the pleuroperitoneal hiatus (foramen of Bochdalek), the most common form of congenital hernia. The hernia allows the entry into the pleural cavity of intestines, spleen, and parts of the liver during intrauterine life. Consequences: displacement of heart and mediastinum to the other side, compression atelectasis. Caveat: severe respiratory insufficiency may occur within minutes to hours. body temperature, basal: syn. early morning temperature. The rectal or oral temperature of the woman taken before getting up. When taken regularly it allows the detection of a rise by 0.4 to 0.6 °C about one day Elfter ovulation. The temperature rise reflects the so-called thermogenic effect of progesterone. The temperature remains elevated during the secretory phase of the menstrual* cycle due to the action of progesterone, drops shortly before menstruation, and remains low during the proliferative phase: biphasic cycle (Fig.). An important tool in diagnosis and treatment of menstruation* disorders and sterility*, and a prerequisite for the temperature* method of contraception. A pregnancy is very likely, if a period has been missed and the basal temperature did not fall. Bonney test (William Francis Victor Bonney, gynecologist, London, 1872-1953):

brachymenorrhea

Bowen's disease, perianal localization Normal (above) and pregnancy pattern (below) x: day of cycle y: temperature (°C)

the elevation of the bladder neck with fingers or an instrument from the fornix; correction of urinary incontinence during elevation is said to indicate stress incontinence (incompetent sphincter). Even if done correctly, the urethra is almost always compressed during the manipulation, and therefore the Bonney test is only of limited use when differentiating stress incontinence* from other forms of urinary incontinence*.

tential; sharply demarcated, 0.5-10 cm large, often solitary, erythematous lesion with psoriasis-like scales and crusts (Fig.). Very slow growth at the periphery; ulceration is a sign of transition to Bowen's carcinoma. After prolonged presence invasion into the corium and metastasis is possible; arsenic was once prescribed but was found to promote it. Location: face, trunk, fingers; also oral mucosa, vulva, or glans penis. Therapy: excision within normal borders, cryotherapy, local cytostatics, radiation therapy.

border, epithelial: t h e a r e a w h e r e t h e l a y -

ered squamous epithelium of the cervix meets the columnar epithelium of the cervical mucoS q u a m o u s epithelial c a r c i n o m a of the cervix b e g i n s in o v e r 90% of the c a s e s at the c e r v i c a l epithelial border!

sa; this border is not fixed and under the influence of the sex* hormones moves from the cervical canal to the surface (cervical ectopia*) and back during the various life stages of women. The constant dynamic processes and physiological changes of the cervical glands predispose the area for epithelial atypia. Cf. colpocytology, colposcopy, transition zone. borderline tumor: a n o n - i n v a s i v e c a r c i n o -

ma; the term is used usually for an ovarian cystoma which is lined by atypical epithelium on still intact basal membranes; potentially malignant; see cystadenoma. Bowen's carcinoma ( J o h n B o w e n , d e r m a -

tologist, Boston, 1857-1941): a carcinoma originating from Bowen's disease with infiltrating, destructive growth, lymphatic metastases; poor prognosis. Therapy: excision, radiation therapy. Bowen's disease: a n i n t r a e p i d e r m a l c a r c i -

noma (carcinoma* in situ) with invasive po-

Bozeman-Fritsch catheter Bozeman-Fritsch catheter ( N a t h a n B o z e -

man, gynecologist, New York, 1825-1905; Heinrich Fritsch, gynecologist, Bonn, 1844-1915): a double-lumen catheter for uterine lavage (Fig.). BPD: abbr. for biparietal diameter* of the fetal head. Bracht's maneuver ( E r i c h B r a c h t , g y n e c o l -

ogist, Berlin, born 1882): an obstetrical maneuver in breech* presentation (Fig, next page): grasping, containing, and lifting the already delivered parts of the infant (back anterior) with simultaneous vigorous fundal pressure and rotation of the fetal body around the symphysis. This allows in many cases the birth of head and arms without other manual assistance (see breech maneuvers, assisted). brachymenorrhea (Gr. brachys short): a shortened and usually slight menstrual bleeding (hypomenorrhea) of a few hours to 1V2 days; due to decreased ovarian or uterine function (e.g. after radiation therapy, endomyometritis, but also during prolonged use of ovulation inhibitors). 29

brachytherapy

brachytherapy: see contact radiation, brain damage, infantile: a collective term for disorders with heterogenous causes and pathological anatomy of t h e developing CNS from the 6th month of pregnancy to the 6th year of life. Frequent causes are hypoxia, infections, intracranial hemorrhages, trauma, bilirubin encephalopathy (see kernicterus), acting pre-, peri-, or postnatally. The infant is especially at risk during the perinatal period (see distress, fetal) and therefore requires particularly close monitoring in this phase. The clinical manifestation of infantile brain damage varies greatly and ranges from barely noticeable mild deviations of personality development to possible fatal outcome (severe cerebral hemorrhage). It is very important to identify mild brain damage (often due to hypoxia) early, because early comprehensive measures (educational, orthopedic, psychological, etc.) in many cases can bring about functionally normal deThe diagnosis of infantile brain damage should be made or suspected no later than the 6th month of life. velopment. It is typical of these cases to be clinically asymptomatic during the first few weeks and months of life. Therefore, all infants at risk (see also newborn, high-risk) from birth onwards should be followed by a pediatrician and be examined every 4 weeks as to the progress of their physical, neurological, and mental development. These examinations should focus on the early recognition of: 1. timely disappearance of primitive reflexes*; 2. physical growth (weight, length, skeletal development, dentition); 3. gross motor development (turning, crawling, sitting, standing, walking); 4. mental development (reaching, playing, receptive and expressive language). Cf. palsy, cerebral. Braxton-Hicks' contractions (John Brax30

ton-Hicks, gynecologist, London, 1823-1897): see contractions, painless (Fig.). Braxton-Hicks' version: an internal obstetrical version* with two fingers through the incompletely dilated os (Fig.). A combined version to a footling from a vertex or transverse lie followed by slight traction on the foot when the os is incompletely dilated; the spontaneous expulsion of the fetus must always be awaited. Prerequisites: the os must admit at least 2 fingers. breast: mamma*. breast, accessory: syn. polymastia, hypermastia; the congenital presence of an additional complete breast anlage (gland, nipple, areola) along the milk* line (Fig.); often associated with other structural anomalies (see mammorenal syndromes); cf. breast, ectopic. breasts and kidneys, supernumerary: the combination of polythelia* and/or polymastia* with uni- or bilateral kidney duplications. In the unilateral manifestation there usually is a renal anomaly on the same side. The ureters of the duplicated kidneys commonly form a common ureter; cf. mammorenal syndromes. breast anomalies: 1. congenital breast anomalies: ectopic, accessory breast*, polythelia*, pseudomamma*, amastia*, hypomastia*; 2. acquired breast anomalies: breast* hypertrophy, mastoptosis*; 3. asymmetries: congenital anisomastia and acquired deformities (after t r a u m a or surgery); 4. gynecomastia*. breast biopsy: see cytology, fine needle, breast, bloody discharge: the discharge of droplets of blood or sanguineous fluid from the nipple; a clinical sign of various causes: esp. cystic mastopathy, papilloma of the milk ducts, not infrequently breast carcinoma. Therefore it is important to evaluate carefully by palpation, cytology of secretions, mammography, galactography. Cf. breast cytology; secretory diseases of the nipple. breast bud: see Tanner stages, breast carcinoma: the most common malignant tumor of women. It occurs predominantly between the 45th and 70th year of life. About one in every 16 women (6%) will have a breast carcinoma. Signs: painless, firm lump (c. 75%), painful lump (c. 10%), secretory* disease of the nipple (c. 10%), localized edema (c. 4%), nipple retraction (c. 3%). Chief complaint: a lump in the breast. None of the signs mentioned are early signs, but rather early signs of an already advanced carcinoma. In breast carcinoma there are no early signs which the woman can detect herself (self-examination: see Fig., page Any unilateral breast node is suspect of a breast carcinoma, especially if it feels firm and irregular. Frequently the node is fused with the skin.

breast carcinoma Y

oD

JpS

250 -

f

r

the upper inner quadrant into the supraclavicular nodes, and from lower quadrants into the retrosternal nodes. Up to 60% of breast carcinomas of less than 2 cm diameter have histologically demonstrable axillary lymph node metastases! Remote metastases: spine, pelvis, liver, lung, pleura, ovaries. Histological classification: see Table 1. Breast carcinoma Histological classification

50 J

iC^Z r

^

^

^

^

j

30 40 50 60 70 80 χ Breast carcinoma: Age-specific incidence in various countries; χ: age (years); y: incidence per 100,000; D: Denmark; S: Sweden; N: Norway; F: Finland; J: Japan 33). Additional clinical signs of breast carcinoma are puckering of the skin and immobility of the skin over the lump, large pores (orange peel skin due to lymphedema), cancer* en cuirasse, open ulcerations; also Paget's carcinoma (an eczematous or ulcerating carcinoma originating from the nipple; see Paget's disease).

Table 1

Non-invasive carcinomas intraductal carcinoma in situ lobular carcinoma in situ Invasive carcinomas invasive ductal carcinoma invasive lobular carcinoma mucinous carcinoma medullary carcinoma papillary carcinoma tubular carcinoma adenoid-cystic carcinoma secretory carcinoma apocrine carcinoma mixed forms Diagnosis: 1. inspection; 2. palpation of all quadrants, axillae, supraclavicular fossae (enlarged lymph nodes). The principal location is the upper outer quadrant (Fig.). 3. ultrasound; 4. radiology: mammography*, especially for clarification of a questionable finding on palpation. It informs about size and location of a breast carcinoma (cf. microcalcifications); also xeromammography*, galactography*; 5. ther-

\

Breast carcinoma: Histology in a large sagittal cut. A scirrhous carcinoma is present below the retracted nipple. Course: the development of a breast carcinoma depends on its location in the breast. The origin is either in the glandular acini or in the milk ducts (intraductal; see comedocarcinoma). Certain types of mastopathy* are considered potential precursor stages of breast carcinoma. Metastasis: lymphatic into the regional lymph nodes. The upper outer quadrantdrains mainly into the axillary lymph* nodes,

Breast carcinoma: Frequency of localization in the quadrants (above), and pathways of metastasis 31

breast carcinoma mography*; 6. breast cytology (exfoliative, fine needle, aspiration, and contact cytology). Stages: TNM-classification (abridged): see Table 2. Breast carcinoma Table 2 TNM-classification (short version) T1 T2 T3 T4

N1 N2 N3

5 2 cm > 2 - 5 cm > 5 cm

Ί a) without fixaI tion to fascia/ ( muscle J b) with fixation to fascia/muscle infiltration into chest wall/skin a) chest wall b) cutaneous edema/infiltration or ulceration c) both moveable axillary nodes a) considered not involved b) considered involved fixed axillary nodes supraclavicular nodes/arm edema

Columbia system: stage A: tumor not fusee to the chest wall, no clinically evident lymph node metastases, no skin edema. Stage B: axillary lymph nodes are affected which are not fixed to the surrounding tissue and have a diameter of less than 2.5 cm. Stage C: additionally one of the following: 1. extensive skin edema on the breast; 2. skin ulcers; 3. fusion of the tumor with the chest wall; 4. involvement of axillary lymph nodes > 2.5 cm diameter; 5. fixation of lymph nodes to surrounding tissue in the axilla. Stage D: carcinoma further advanced and characterized by: l.two or more signs of stage C; 2. intracutaneous metastases; 3. inflammatory form of the carcinoma; 4. clinically apparent supraclavicular metastases; 5. parasternal metastases; 6. arm edema; 7. remote metastases.

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κ «1

1 2 I I T W ι 1 I ; Μ ' ifljtffe 1 4 i P w Μ®4 'im^t Breast carcinoma: Infrared-color-thermography of a leftsided scirrhous breast carcinoma. Color calibration scale is below; adjacent colors indicate a difference of c. 1 °C. motherapy is indicated only with demonstrated metastases: 1. steroids (estrogen, progesterone, and prolactin) or antiestrogens (e.g. tamoxifen) in order to change the hormonal environment (additive hormonal therapy); effective in only about 30-40%. Prerequisite: the presence of specific hormone* receptors; unless they are present, hormone therapy is futile; ablative hormonal therapy: see oophorectomy: 2. cytotoxic drugs in progressive breast carcinoma: transient use of multiple agents with about 60% response, but serious side effects.

The term "early cancer" is justified according to current knowledge in: 1. non-infiltrating carcinoma: lobular or ductal carcinoma in situ; 2. infiltrating carcinoma: up to a diameter of 0.5 cm. Therapy: the radical operation of Halsted (see Halsted's operation) has been replaced by the modified radical mastectomy* (comparable 10-year survival rates). Postoperative radiation therapy is now used only with histological demonstration of carcinoma cells in distant regional lymph nodes. The clinical experience has been that treatment results are not better with routine pre- and postoperative radiation. The surgical removal of a breast is not only a physical but also a severe psychological trauma for the woman and requires sensitive guidance which should include the partner. Information about self-help groups and cosmetic devices (prostheses) is very important. Che-

Breast carcinoma: Noticeable retraction of the nipple (arrow) from a carcinoma with a diameterof 3.5 cm Prognosis: important is the stage of the patient at the onset of therapy. Five-year survival without recurrence: stage A: up to 90%; B: 40-50%; C: up to 10%. Early cases (minimal cancer, early cancer, lobular carcinoma in situ, preinvasive carcinoma, TjNoMo-nomenclature still not defined satisfactorily) under some circumstances can be treated conservatively

breast milk with breast-preserving operations (see mastectomy, subradical). Follow-up: most local recurrences and remote metastases occur within 3 years after surgery, therefore the patients are seen every 3 months during this time (chest radiography, bone scan, mammography of the other breast, gynecological examination). Cf. tumor markers (CEA), lymphedema. The instruction of all patients in regular self-examinations is an indispensable part of counselling in health maintenance examinations.

ft

Breast carcinoma: Self-examination: palpation of breast and axilla breast, cystic disease of: strictly, the term applies to a rare congenital anomaly of the breast; it is often used for cystic mastopathy*. breast cytology: the cytological examination, esp. of secretions, from the nipple (exfoliative cytology*), aspiration material from cysts, or of biopsy material from solitary nodes (fine needle cytology*); the methods are considered safe in breast carcinoma* with regard to hematogenous tumor spread. Indications: esp. in (pathological) secretions of the breast outside of lactation* (secretory* disease of the nipple; bloody discharge from the breast*); for the clarification of cystic changes (e.g. mastopathy*) and questionable findings on palpation with negative or questionable radiographic findings; for the diagnosis of conditions where a surgical procedure is contraindicated (e.g. the differential diagnosis between mastitis* and an inflammatory breast carcinoma; in inoperable cases determination of the type of carcinoma before radiation therapy). Cf. cytology, diagnostic. breast, ectopic: breast tissue outside of the milk line and remote from the normal breast gland, sometimes without nipple and areola, i.e. without drainage; predominantly in the left axilla. Cf. breast, accessory; mammorenal syndromes. breast feeding: see nursing, breast hypertrophy: abnormally large breast; an acquired anomaly due to excessive growth of all parts of the organ (gland, connective and fatty tissues), often associated with mastoptosis*. 1. puberty hypertrophy: onset to-

gether with menarche, uni- or bilateral breast hypertrophy; may require reduction mammoplasty. 2. pregnancy hypertrophy; usually reversible. 3. breast hypertrophy in the mature woman (etiology unknown). Cf. mammoplasty, gynecomastia. breast hypertrophy, neonatal: the swelling of the breast of newborns caused by hormonal action from the mother. Cf. witch's milk. breast milk: the secretion from the female breast during lactation; it contains the inhibins lysozyme, lactoferrin, neuraminic acid, and specific immune globulins (esp. IgA), among other substances, contributing to the lower susceptibility of breastfed infants to infections and allergens; see Table 1 for composition. Under the influence of placental hormones (estrogen, progesterone, HPL*) and prolactin* during pregnancy the breast parenchyma grows, and the glandular cells contain more fat droplets. Lactation* (secretion of milk), however, is initiated only after the cessation of the inhibition by the placental hormones (placental separation). In the first days after delivery colostrum* is produced, then transitory milk, and after 10-15 (rarely 21) days mature milk. "Let-down" of the milk (from the 3rd or 4th postpartum day) is influenced by oxytocin*. The physiological stimulus for the persistence of milk secretion is suckling with emptying the breast as completely as possible. Various noxious substances (stimulants, environmental toxins) and drugs (Table 2, page 34) may enter breast milk. The extent is related to solubility, protein binding, lipophilic property, ionization. For medications the concentration in the breast milk is on the average one-tenth the therapeutic level, usually harmless for the infant, although there is the occasional risk for accumulation. Therefore the prescribing of drugs during lactation period should be discussed with the pediatrician and breastfeeding, if appropriate, be interrupted. Cf. weaning. Breast milk Component

Table 1 Average amount in g/100 ml

Protein 1.5 Casein 0.4 Lactalbumin 0.4 Lactoglobulin 0.7 (immune antibodies) Fat 4.5 Carbohydrates 7.0 Minerals 0.2 Vitamin A c. 0.04 Vitamin C c. 0.005

Range in g/100 ml 0.7-2.0

1.3-8.2 4.5-9.5

The nutritive value of breast milk ranges between 188 kJ ( ^ 4 5 kcal) and 502 kJ ( ^ 1 2 0 kcal), the average value is 314 kJ ( £ 7 5 kcal) per 100 ml. 33

breast-milk jaundice Table 2

Breast milk Drugs during pregnancy and lactation Drug Antibacterials sulfonamides nitrofurantoin, nalidixic acid metronidazole Antibiotics penicillins tetracycline chloramphenicol aminoglycosides Hormones oral contraceptives

Action on embryo or infant; comments risk of bilirubin encephalopathy risk of hemolysis in G-6-PD deficiency (rare!) high concentration in milk; avoid nursing during short-term treatment sensitization, development of resistant bacteria, overgrowth formation of calcium complexes leads to staining of nails and later the deciduous and permanent teeth, reversible growth inhibition "grey baby" syndrome ototoxicity in high doses

cortisone Psychopharmaca, hypnotics

possible gynecomastia in boys and proliferation of vaginal epithelium in girls use only for vital reasons sedation, hypnotic states

Sedatives

muscular hypotonia

Anticonvulsives Phenytoin, phenobarbital valproate

carbamazepine Diuretics Antihypertensives reserpine Anticoagulants coumarin heparin Analgesics, antirheumatics meperidine, opiates salicylates ergotamine methylergometrine Thyreostatics

little transfer into milk; permitted easy transfer into milk; avoid unknown long half-life, risk of accumulation, hypokalemia, thrombocytopenia, bradycardia, hypotension hypersecretion of nasal mucosa, disturbed temperature regulation, lethargy, depression risk of bleeding does not transfer into milk; permitted some use permitted dose-dependent coagulation disorders vomiting, diarrhea permitted risk of goiter

Laxatives

avoid absorbable laxatives

Vitamin D preparations

risk of hypocalcemia depending on amount of routine vitamins taken simultaneously

breast-milk jaundice: current understanding differentiates two forms: 1.late onset; familial occurrence; after the physiological jaundice (see icterus neonatorum) the serum bilirubin level rises until the 10th to 15th day. Cause: poorly defined peculiarities of the individual breast* milk. Mode of action: inhibition of UDP-transferase and/or specific enhancement of enteric resorption of bilirubin. Incidence: once cited as a few percent but in recent studies in u p to 30% of breastfed infants. 2. early onset: moderate hyperbilirubinemia in the first 3 to 5 days. Cause: increased enteric resorption of bilirubin. Incidence: up to 25% of breastfed infants. Recommendation: weaning is not necessary in either form, but the bilirubin levels need to be

checked frequently. In the early form: frequent nursing, more than 8 times in 24 hours. This stimulates gut motility independent of the ingested milk volume and thus promotes the excretion of bilirubin in meconium. If the bilirubin rises to critical levels, nursing should be decreased or stopped temporarily. A related fall in bilirubin may confirm the diagnosis; in the interim the breast should be pumped for the maintenance of lactation*. After resumption of nursing the bilirubin in the late form remains on a plateau for a while. In erythroblastosis neonatorum the breast milk may also contains irregular antibodies, but this is not a contraindication for nursing*, because the antibodies are not absorbed in the gut.

bromocriptine

breast prosthesis: there are several types of breast prostheses: 1. brassiere prosthesis of cotton or silicone for the initial period after mastectomy* or for permanent use; 2. prosthesis, permanently implanted during mammoplasty*; silicone prostheses with a gel core and several layers are used primarily (Fig.). A

rior surface of the fetus. Full breech: next to the buttocks are one (incomplete) or both feet (complete footling breech) palpable: a more favorable condition, because it allows far better soft tissue distension for the aftercoming head. Complete and incomplete footling and knee presentations are those in which one or both feet or knees precede the buttocks. Cause: failure of fetal rotation in utero, prematurity, anomalies of pelvis and birth canal, twins, low-lying placenta, fetal anomalies. Procedure: attempt at external version* in the 37th or 38th week with c. 60% success. Brenner's tumor (Fritz Brenner, pathologist, Frankfurt, born 1877): a usually benign, almost always unilateral, ovarian tumor which

Breast prosthesis: Implantable silicone prosthesis c o n f o r m s to positioning by corresponding shift and mass flow.

frequent complication is capsular fibrosis*. The implantation of a prosthesis may need to be preceded by the generation of a sufficiently large pocket by temporarily implanting a skin expander which is distended via a subcutaneous valve to the desired size. breast, suspensory ligament of: s e e l i g a -

mentum suspensorium mammae. breech

maneuvers,

assisted:

obstetric

maneuvers for the delivery of breech* presentations which have been delivered to the level of the lower angle of the scapulae. Procedures: the one-stage maneuver of Bracht* for delivery of arms and head; if no success: a two-stage maneuver for 1. shoulders and arms (Müller's*, Levsefs* maneuver, or classic arm* extraction); 2. the head (MauriceauVeit-Smellie maneuver). Cf. extraction. breech presentation: the fetal position in which the buttocks and/or lower extremities form the presenting part (3% of all births). The

delivery requires assistance (see breech maneuvers, assisted). Classification: according to the presenting part into breech (Fig.), knee, and footling presentations. Frank breech: the fetal legs are fully extended against the ante-

Brenner s tumor, ovary

may reach a size of up to 20 cm in diameter. It is derived from celomic epithelium (heterotopic determination to urothelium); histology: fibrous stroma and round epithelial, sometimes mucinous foci. Some Brenner's tumors have endocrine activity and produce estrogen. In the very rare malignant version the epithelial component degenerates malignantly. See tumors, ovarian. Braus' mole: also subchorial hematoma; a partial formation of a hematoma between chorion* and decidua*, causing an inward bulge of the amniotic cavity; see mole, blood. bromocriptine (INN-Ε): bromocriptinum (INN-L), 2-bromo-a-ergocriptine (IUPAC); CAS-No. 25614-03-3; C32H40BrN5O5; molecular weight 546.51; dopamine antagonist, prolactin*inhibitor, belongs to the group of the cyclic peptides of the lysergic acid derivatives; because of a 1000-fold higher affinity to the

Br

Bromocriptine 35

brow presentation dopamine receptors of the anterior pituitary lobe, the release of prolactin* is inhibited. Therapeutic use: for primary and secondary inhibition of lactation, in galactorrhea, milk retention, mastitis, prolactin-induced premenstrual symptoms, menstruation disorders, amenorrhea, sterility; also in acromegaly, Parkinson's syndrome, prolactinoma*. Cf. lisuride. brow presentation: a rare (1 of 2-3000 births), anomalous fetal deflexion presentation where the forehead remains the presenting part until delivery of the head. A brow presentation is the least favorable and most dangerous of all vaginally deliverable vertex presentations because of the largest head circumference presented (35-36 cm; see skull measurements) and the asynclitism*. Cf. position, fetal. brow presentation, posterior: an anomalous presentation in which the parietal area forms the presenting part, and the head is neutral between flexion and deflexion. See position, fetal.

36

Brunschwig's operation (Alexander Brunschwig, surgeon, New York, 1901-1969): pelvic exenteration; an extensively radical operation for advanced genital carcinoma with evisceration of the pelvis, ureteral diversion to the intestine, and colostomy. bulbi vestibuli (Lat. bulbus onion, swelling): paired erectile tissue bodies, homologous to the unpaired male corpus spongiosum penis, which are located at the base of the labia minora pudendi and each covered by a musculus bulbospongiosus. bulbospongiosus muscle: see musculus bulbospongiosus. bulimia (Gr. bous ox; limos hunger): syn. hyperorexia; morbidly increased appetite. An ambiguous symptom with organic (e.g. hypoglycemia) or psychological causes (e.g. in combination with anorexia). In bulimia* nervosa the individual simultaneously attempts to control the body weight. Cf. eating disorders, psychogenic. bulimia nervosa: a psychogenic eating disorder in which excessive amounts of highcalory food are consumed within a short time with subsequent attempts to keep the body weight within (sub)normal limits by periodic fasting, self-induced vomiting, or abuse of laxatives and diuretics. It is estimated that 2-4% of all women between 18 and 35 years are affected. It is often preceded by morbid obesity or anorexia* nervosa. Complications: hypokalemia, cardiac arrhythmia, renal damage, swelling of the parotid gland, dental changes, gastroenteric reflux, acute gastric dilatation, chronic hoarseness, convulsions. Therapy: psychotherapy (e.g. behavioral modification). See also eating disorders, psychogenic.

c

cachexia (Gr. kakos bad; hexis habit): a condition characterized by loss of body fat and being underweight. Many causes: exogenous (poor caloric intake, malignant tumors, infections, poisonings, malabsorption, anorexia*); endogenous, divided into constitutional, psychogenic (anorexia* nervosa), and endocrine factors (Simmonds' disease; see eating disorders, psychogenic; hypopituitarism). calendar, menstrual: a graphic recording of time, duration, and amount of menstrual

flow

1.

2.

3.

4.

5.

cycle 6.

heavy normal light

Menstrual calendar bleeding, used in the evaluation of menstruation* disorders (Fig.). Call-Exner bodies (Friedrich von Call, physician, Vienna, 1844-1917): small, round vacuoles, containing follicular fluid, surrounded by radially arranged granulosa cells,

canalis inguinalis: inguinal canal; in women contains the round ligament of the uterus (in men the spermatic cord). canalis obturatorius: obturator canal; laterosuperior opening in the membrane of the foramen obturatum of the hip bone; contains a., v., and n. obturatorius. canalis pudendalis: see Alcock's canal, canalis sacralis: sacral canal; continuation of the vertebral canal in the sacrum, cancer (Lat crab): see carcinoma, cancer en cuirasse (Fr. cuirasse breastplate): the endstage of a breast* carcinoma left untreated, now rarely seen. The affected side of the chest is encased by a tumorous layer consisting of the regional lymphatic intracutaneous spread of the cancer and development of a rigid thoracic skin, often of a dark red color. Candida albicans (Lat Candidus shiny, white): a thin-walled, gram-positive, nonsporeforming, potentially pathogenic yeast of oval or round shape which grows saprophytically by budding in skin folds, mouth, intestines, and vagina. When general or local defense mechanisms are compromised, Candida

Candida albicans: Pseudomycelia and oval budding forms Call-Exner bodies: Finding in the membrana granulosa of a maturing ovarian follicle in the membrana granulosa of mature follicles in the ovary*. They may also occur in granulosa*-cell tumors of the ovary, where they are arranged randomly and are a diagnostic criterion for this kind of tumor, canalis (Lat): (anat) canal, canalis cervicis uteri: cervical canal; canal of the neck of the uterus*, cf. cervix uteri.

albicans enters a parasitic growth phase, forms pseudomycelia (see Fig.), and causes diseases of skin, mucous membranes, and internal organs. Candida vulvitis: see Candida vulvovaginitis.

Candida vulvovaginitis: a vulvovaginitis* caused usually by Candida albicans, but also by other Candida species, characterized by marked reddening and usually a typical greywhite coating in the vulva, vaginal wall, or cervix which may bleed when scraped. Common in infancy and in patients with diabetes melli-

capacitation

•·.· -J.

*

r • *

Λ

J P *

V

•

•

·

1.

V

j m Candida v u l v o v a g i n i t i s : C o l p o c y t o l o g i c a l finding of small, round, sharply b o r d e r e d budding cells

tus, immune suppression, leukemia, and other debilitating diseases, as well as with use of antibiotics, glucocorticoids, oral contraceptives, and cytostatics. During pregnancy the incidence is increased; a risk of neonatal infection is being discussed. capacitation (Lat. capacitas capability): the fusion of plasma and the achromosomal membrane of sperm cells. Enzymes are released which facilitate the entry of the sperm into the ovum. It is part of the mechanism by which the spermatozoa are rendered capable of fertilization. cap, cervical: a firm, synthetic cover over the cervix which is placed postmenstrually (usually by a physician). It stays in place by suction and prevents the entry of sperm from the vagina into the uterus; it must be removed before the next menstruation. This contraceptive method has not found wide use. PearlIndex (from the older literature): 7. caput succadeneum (Lat. succeeding head): a hemorrhagic-serous infiltration of the skin area of the presenting* part during birth, consequently in vertex presentations, usually seen on the scalp near the posterior fontanel. The infiltrate is between skin and periostium and starts after the rupture* of the membranes during the passage of the fetal skull through the pelvic outlet carcinogenesis, transplacental: the prenatal initiation of the development of neoplasms which frequently are only discovered later postnatally; triggered by chemical (e.g. directly acting alkylating agents) or physical factors (e.g. ionizing radiation). 1. induction by chemical agents: from animal experiments over 100 substances have been identified; all substances are also carcinogens for adult animals. It is often possible to induce tumors with doses insufficient for tumor formation in the mother; in humans the intrauterine exposure to diethylstilbestrol* is associated with the appearance of clear-cell carcinoma in the vagina (latency period up to 18 years). 2. induction by ionizing radiation: the literature about this is still rather controversial. Several studies found after intrauterine radiation exposure (medical radiation, atomic bomb victims) an increased incidence of neoplasms, 38

esp. leukemias. Radiation doses of lOmGy (1 rd) might cause a doubling of the spontaneous malignancy rate. Essentially, the question is still open and more studies are needed. carcinoma (Gr. karkinos crab): abbr. ca.; malignant epithelial tumor. Classification according to cell origin and differentiation (cell type): 1. squamous cell carcinoma (cornified, non-cornified); 2. adenocarcinoma (tubal, alveolar, papillary, mucoid, signet-ring cell carcinoma, solid adenocarcinoma; special form: adenoacanthoma*); 3. undifferentiated carcinoma (histol. identification of tissue of origin is not possible). Classification according to content of connective tissue (volume relationship between epithelial and connective tissue): 1. medullary ca. (proportion of epithelial tissue over 50%, soft consistency); 2. simple ca. (carcinoma simplex; relationship about 1:1, medium-firm); 3. scirrhous ca. (connective tissue content over 50%, firm consistency). Tumor spread occurs through local invasive-destructive growth with extension to neighbouring tissue, organs, and organ systems or as lymphangitis* carcinomatosa (per continuitatem) and through metastasis (formation of so-called satellite tumors, metastases). Cf. carcinoma in situ, precancer. carcinoma, anal: a carcinoma located at the anal rim or in the anal canal (usually a squamous epithelial carcinoma, rarely an adenocarcinoma); relatively rare (c. 4% of rectal carcinoma). Anal carcinomas are always palpable by digital rectal examination; the examination of toe inguinal region (lymph node metastases!) is mandatory. Therapy: generous excision, followed by radiation therapy; sometimes resection of the rectum after radiation, en-bloc removal of lymph nodes. 5-year survival: 50-85%. carcinoma, embryonal: an extremely rare germ cell tumor of the ovary, affects mostly girls and young women. Macroscopically solid, microscopically made up of undifferentiated embryonal, occasionally extra-embryonal cells. Extremely poor prognosis. See tumors, ovarian. carcinoma, endometrial: a cancer of the uterus occurring most commonly in postmenopausal women; in younger women it is often associated with a polycystic* ovary syndrome. The frequency has increased during the past years, it is now as common as cervix* carcino75-80% of all women with endometrial cancer are in the climacteric age range. ma. Histology: adenocarcinoma of the endometrial type (over 80%); the remainder (mucinous, clear-cell, serous-papillary carcinoma; rarely adenoacanthoma*) originate often from heterotopic metaplasias of the pluripotent müllerian epithelium, occur usually in late menopause, and have a distinctly poorer prognosis. Estrogen-mediated overstimulation without compensatory gestagen activity leading to premalignant endometrial changes

carcinoma, rectal Endometrial carcinoma T N M classification a n d F I G O s t a g e s (short version) UICC Tis T1 T1a T1b T2 T3 T4 M1

FIGO c a r c i n o m a in situ limited to the c o r p u s c a v u m 8 cm extension to cervix extension b e y o n d uterus, but within pelvis extension to bladder or rectum, b e y o n d pelvis involvement of distant organs

0 I

la lb

II III IVa IVb

which has not perforated the basilar membrane (intra-epithelial regeneration with a high degree of atypical epithelium which can not be differentiated histologically either in its composition or structure from a carcinomatous epithelium). One can not predict when a c.i.s. will change into an invasive carcinoma (often long latency). The c.i.s. is considered the obligatory initial stage of a carcinoma and must be histologically differentiated from microinvasion or early carcinoma (basement membrane already ruptured); see Fig. next page. Cf. premalignant changes.

Endometrial carcinoma: Well differentiated adenocarcinoma (above), well differentiated papillary adenocarcinoma (middle), and poorly differentiated papillary carcinoma (below)

(esp. adenomatous hyperplasia*) is the principal pathogenic explanation. TNM-classification and FIGO-stages: see Table. Metastases spread along paraaortic and pelvic lymph nodes depending on localization and direction of growth, in c. 10% into the ovaries; hematogenous metastases in lungs (via inferior vena cava), liver, skeletal system, and brain. Signs and symptoms: intermittent, slight uterine bleeding, menorrhagia*, metrorrhagia*, sometimes laborlike pain. Complications: esp. pyometra*. Diagnosis: aspiration* biopsy, fractionated curettage* for histological examination, computed tomography. Therapy: surgical (hysterectomy*, oophorectomy*, possibly a part of the vagina, Wertheim's* operation), radiation therapy, gestagens*. Cf. jet-wash technique, ichthyosis uteri, screening examinations. carcinoma in situ (Lat. i n s i t u i n t h e n o r m a l

place): predecessor of invasive cancer (stage 0), so-called superficial carcinoma; carcinoma*

Carcinoma in situ: Findings within a cervical gland carcinoma of the uterus: s e e c a r c i n o m a ,

endometrial; cervix carcinoma.

carcinoma, ovarian: s e e t u m o r s , o v a r i a n , carcinoma, rectal: a f o r m of c a r c i n o m a of

the colon. 70-90% of all colorectal carcinomas occur in the distal colon and rectum*. Rectal carcinoma occurs in both sexes most commonly between the 50th and 70th year of life. Etiology: often develops from adenomatous or villous intestinal polyps; some forms of colonic polyposis are considered as premalignant tumor*. Histology: adenocarcinoma (c. 90%), mucoid carcinoma (c. 10%), rarely squamous carcinoma (in the anal area) and others. Lymphatic metastases spread relatively late depending on the localization: in the upper third of the rectum toward the mesentery, in the mid39

carcinoma, scirrhous squamous epithelium

columnar epithelium

proliferating epithelium

reserve cell hyperplasia

J-(ion Λοοαοοοο αSa

mild to moderate dysplasia (squamous cell origin)

mild mucoid dysplasia (reserve cell type)

A polypous, broad-based rectal carcinoma: M o s t are digitally palpable, but, because of subsurface growth, t h e degree of malignancy o f t e n is ascertained only by serial histological section; superficial biopsies are inadequate.

i

Wim&m severe dysplasia (squamous cell origin)

severe mucoid dysplasia (reserve cell type)

•4,

carcinoma in situ (squamous cell origin)

carcinoma in situ (reserve cell type)

microinvasive carcinoma, net-like infiltration (spray-type)

microinvasive carcinoma plump infiltration

loss. Occult as well as massive hemorrhages may occur. Rectal carcinoma may penetrate into vagina or bladder and form fistulas. Diagnosis: demonstration of occult blood in the stool, rectal examination (about one third can be palpated), rectoscopy* (rectosigmoidoscopy) with biopsy, radiography with contrast enema. Therapy: surgical: en-bloc resection including the lymph nodes of the regional drainage system with maintenance of a 5 cm safety margin; if possible, maintenance of fecal continence (Dixon's operation); tumors in the distal third require an abdomino-perineal resection with a sigmoidostomy (Miles' operation); for small tumors local excision (electro-, cryo-, or laser surgery) may suffice; sometimes pre- or postoperative radiation therapy. carcinoma, scirrhous (Gr. skirrhos hard): see carcinoma.

I cornified squamous cell carcinoma

ί

non-cornified squamous cell carcinoma

I

mixed form, no longer able to be differentiated mucoepidermoid carcinoma

J

Carcinoma in situ: Carcinogenesis on the cervix originating f r o m t h e proliferating layer of the multilayered s q u a m o u s epithelium and f r o m the subcylindrical (reserve) cells of the cervix die third additionally into the pelvic lymph nodes, in the lower third also inguinally. Hematogenous metastases spread Ana the portal circulation into the liver initially (later lungs, skeleton); low tumors metastasize primarily via branches of the inferior vena cava into the lungs. Signs and symptoms: bloody and mucoid stools, bowel irregularities (constipation or diarrhea), meteorism, flatulence, perineal pressure sensation; later, anemia and weight 40

Rectal carcinoma: Almost V3 of all colon carcinomas are located in t h e recto-sigmoid; V 3 of rectal carcinomas are accessible to digital examination.

cardiac anomalies, congenital carcinomatosis, peritoneal: the spread of carcinomatous metastases throughout the entire peritoneum. carcinoma, vaginal: a rare carcinoma (c. 0.6-2.0% of all female genital tract carcinomas) originating from the vagina, mainly in elderly women; usually located in the upper third of the posterior wall; early lymphatic metastases into the pelvic and inguinal nodes. Histologically, primary vaginal carcinomas are almost always squamous cell carcinomas, rarely adenocarcinomas. Surgical treatment is possible In vaginal carcinoma, esp. in the lower third of the vagina, the inguinal lymph nodes become markedly enlarged quite early. only in small tumors, radiation therapy is the usual intervention; results are relatively poor (c. 35% 5-year survival). Secondary vaginal carcinomas are tumors which expanded into the vagina from other genital sites (esp. cervical or vulvar carcinoma) or are metastases of extragenital carcinomas, e.g. hypernephroma, breast carcinoma; cf. tumors, vaginal. carcinoma, vulvar: a keratinizing squamous cell carcinoma of the vulva* which affects women usually between 60 and 80 years (c. 4% of all female genital cancers); most frequently localized at the labia majora; because Findings suspicious for vulvar carcinoma are: - small, wart-like formations, - small, weeping nodules, - minor bleeding from scratching of areas which actually are already minute ulcerations of a vulvar Carcinoma. of the rich lymphatic supply of the vulva, there is early metastatic spread, usually at first to the inguinal lymph nodes. See the table for TNM-classification and FIGO-stages. Premalignant* conditions for vulvar carcinoma are

Vulvar carcinoma: Keratinizing squamous epithelial carcinoma of the vulva

kraurosis* and leukoplakia* vulvae. Therapy: electrosurgical excision or vulvectomy* and possible postoperative radiation therapy. Vulvar carcinoma TN Μ classification and FIGO stages {short version) UICC T1 T2 T3 T4 N1 N2 N3

FIGO £ 2 cm > 2 cm lower urethra/vagina/ perineum/anus upper urethra/bladder/ rectum/pelvic wall ipsilateral/moveable biiateral/moveable fixed

I II III IV (part)

a

Vulvar carcinoma: Lymphatic drainage of the vulva; a: inguinal lymph nodes; b: glans of the clitoris; c: external urethral orifice; d: labia minora; e: vaginal orifice; f: anus cardiac activity, fetal: as an indication of intrauterine life and an intact early pregnancy, fetal cardiac activity is identifiable from the 8th gestational week with the Α-scan (cf. ultrasound diagnosis), from the 10th week with the B-scan, and from the 12th week with Doppler sonography. cardiac anomalies, congenital: cardiovascular malformations due to intrauterine developmental disturbances, mostly due to exogenous influences, but the actual etiology often remains unknown. Cardiac anomalies account for 1-2% of childhood disease, but for more than 8% during the first 4 weeks! The prognosis depends on the defect, with only 40% surviving the first and only 30% the 10th year. Congenital cardiac anomalies can be classified according to various principles: hemodynamic (Bing), by considering the more or less complete separation of the systemic and pulmonary circulations (shunt). The 1st group usually has few clinical signs, remains often unrecognized or is diagnosed incidentally, whereas the 2nd group is characterized clinically and in X-ray and ECG by increased pulmo41

cardinal ligament nary blood flow of varying degrees. This leads eventually to complications (recurrent bronchitis, pneumonia, secondary vascular changes, e.g. pulmonary artery sclerosis) which determine the outcome considerably. This decrease in life expectancy and early developmental impairment applies in particular for the defects of the 2nd group with right-toleft shunt and obligatory cyanosis, because of the additional decreased oxygen saturation of the blood. These together with the defects of the 3rd group constitute the cyanotic congenital cardiac anomalies („blue babies"). The 3rd group is characterized by decreased pulmonary blood flow and will cause early static developmental delay and decreased exercise tolerance („squatting") because of the impaired oxygen supply to the entire body (small pulmonary blood volume and admixture of venous to arterial blood); typical signs are the squatting position and digital clubbing. In some of the defects right heart failure is the principal clinical problem. Accurate diagnosis requires specialized methods of examination (echocardiography, cardiac catheterization, dye dilution curves, angiocardiography). cardinal ligament: ligamentum cardinale uteri; see ligamentum latum uteri, retinacula uteri. cardiomyopathy (Gr. kardia heart; mys muscle; pathos disease): the occurrence of a cardiomyopathy during pregnancy or postpartum is known as Meadow's syndrome. cardiotocography (Gr. tokos childbirth; graphein to write): the continuous simultaneous recording (cardiotocogram, CTG) of fetal heart rate and uterine contractions during late pregnancy (antepartum c.) and during birth (intrapartum c.). The main objectives are the monitoring of the fetus and the diagnosis of intrauterine hypoxia. Antepartum cardiotocography can be repeated, if the findings are suspect or unclear (see oxytocin challenge test). Three methods: 1. direct fetal electrocardiography: recording of fetal ECG-potentials from a part of the fetus (e.g. from the scalp after rupture of the membranes), or indirectly from the maternal abdominal wall. 2. phonocardiography: heart rate recording with a microphone. 3. Doppler sonography: demonstration of the motions of the heart with ultrasound. Methods for recording contractions (tocography*): 1. abdominal recording; a transducer indicating changes in pressure measures contractions*; 2. intrauterine recording: the transducer is connected with the amniotic cavity by a fluid-filled catheter which is introduced transcervically. The variables considered for interpretation are: 1. baseline* fetal heart-rate; 2. deceleration* types; 3. oscillations*. There are no uniformly accepted standards as to the meaning and importance of the variables. Attempts at computerized analysis are in progress; a semiquantitative interpretation is available with the CTG-score. Cardiotocography allows, together with fetal* blood analysis, intensive monitoring of the fetal circulation and gives early warning of intrauterine fetal risk. 42

care, prenatal: the counselling of the pregnant woman and the monitoring of her pregnancy by physician and midwife. The object is to discover early deviations from a normal course of pregnancy (see pregnancy, highrisk), and to prevent permanent damage during and after pregnancy. carneous mole: see mole, carneous. carrier: (genetic) an individual who transmits the predisposition to a disease from the preceding generation to the next, whilst he himself is healthy. The term is used in particular for women who are heterozygous for an X-chromosomal recessive gene; half of her sons have this recessive characteristic, e.g. in hemophilia. Cf. diseases, genetic. carunculae hymenales myrtiformes (dim. of Lat. caro flesh): myrtle-leaf-shaped fleshy warts, the shrivelled remains of the ruptured hymen, generally after delivery. castration: the operative removal of the gonads* (testes or ovaries) or the inactivation of the gonads by radiation (radiation* castration). Consequences: 1. in childhood: "castrate" voice, lack of secondary sex characteristics, delayed epiphyseal closure causing elongated extremities, psychosexual developmental delay; 2. in adulthood: cessation of fertilizing and conceptional ability; in addition to somatic signs marked psychic changes, often depression. Libido is diminished, the sexual object choice is unchanged (relevant in cases of criminal sexual assault situations). castration, pharmacological: see contrasexual therapy. castration, surgical: see oophorectomy, caul: remnants of the amnion which cling to the infant's head like a cap; in folklore considered a lucky sign. cautery, hot wire: a technique for thermotherapy (90 °C) of benign erythroplakia on the cervix; painless removal of nabothian cysts, treatment of chronic cervicitis, prophylaxis of cervix carcinoma. cavity, amniotic: see amnion, cellulite: colloquial term for a non-inflammatory constitutional, circumscribed deposition of fat with mild lymphatic congestion and slight (mucoid) edema in the connective tissue, localized in thighs and buttocks, esp. in younger women; „mattress" phenomenon (connective tissue septa form net-like indentations) and orange-peel skin (painful, funnelshaped impressions after pinching) are usually present but have no pathological relevance. Therapy is not possible; for prophylaxis weight reduction and fitness programs are recommended. centers, genital: the genital centers are regulated by the brain; their destruction leads to impotentia coeundi; destruction of higher centers often to priapism; cf. sex center. cephalhematoma (Gr. kephale head): a hematoma between periosteum and bone, a subperiosteal hematoma; fluctuating, up to chicken egg-sized, hemispherical, abnormal swelling on the skull of a newborn. In contrast to caput* succedaneum, a cephalhematoma does not extend across sutures. Cause: tearing

cervix carcinoma

of vessels between periosteum and bone during the passage of the head through the birth canal, when the scalp shears along the flat skull bones. In contrast to caput succedaneum, the hematoma lifts the periosteum from the bone. cephalometry, intrauterine: the measure-

ment of defined diameters and circumferences of the fetal head in utero; most often that of the biparietal diameter (BPD). The result relates to fetal weight and gestational age. The method used currently is ultrasound* diagnosis. The growth of the BPD in relation to gestational age is almost directly proportional. Generally a BPD of > 92 mm corresponds to a weight of 2500 g or more and a gestational age of 35 weeks or more. However, in high-risk pregnancies this relation may not apply, and additional measurements, e.g. thoracometry, are necessary for the evaluation of fetal growth disturbances; see also size, fetal (Fig.). cerclage (Fr. cerclage a circular band): the surgical closure of the cervical canal in pregnancy in cervical incompetence*. Types: 1. cerclage without colpotomy (McDonald) with non-resorbable suture material or a mersilene tape; 2. cerclage with colpotomy (Shirodkar) where the bladder is dissected to the level of the internal os; 3. cervix closure (Wurm-Hefner) by the placement of two nonresorbable U-sutures which are offset to each other by 90°; 4. total closure of the os (Szendi) by interrupted sutures, c. 1 cm apart. Non-resorbable sutures are removed in the 38th to 39th week, with the onset of labor, rupture of membranes, or hemorrhage. v cervical canal: see canalis cervicis uteri, cervical factor: a collective term for the functional cyclic changes of the cervix and

cervical mucus*. A pathologic cervical factor is the presence of: 1. endocrine and immunologic disorders (e.g. lack of capacitation, formation of sperm antibodies) as factors impeding conception (in sterility*); 2. morphological-pathological changes as factors impeding the ability to carry to term (in infertility*); see cervix score. cervical mucus method: see Billings' ovu-

lation method. cervicitis: inflammation of the mucosa in the cervical canal. Primary or secondary mucosal changes, accompanied by vaginal discharge*, may affect deeper layers to the parametrium. Occurs in gonorrhea, postpartum colpitis*, postabortive, or with the use of IUCDs. A cervicitis may be the origin for an ascending infection*; see endometritis. cervix (Lat neck): cervix* uteri; the part of the uterus which extends into the vagina. cervix carcinoma: clinical classification into carcinoma of the cervix* and of the cervical canal, often with a barrel-shaped swelling.

Cervix carcinoma: 1: stage I (cervical canal ca., colposcopically not visible; 2: stage II a; 3: stage II b; 4: stage III a; 5: stage III b; 6: stage IV 43

cervix carcinoma Occurrence: once cervix carcinoma was the most common genital carcinoma in women, now its incidence is equal to that of endometrial carcinoma* (due to earlier recognition of precancerous stages, and increase in endometrial carcinoma); the incidence is highest in the 5th and 6th decades and probably is promoted by mechanical and inflammatory factors, and poor genital hygiene (also that of the partner). Histology: mostly squamous cell carcinoma (90%), rarely adenocarcinoma (c. 5%), mixed forms and those originating from Gartner's ducts (c. 5%). Each woman over 25 years should have a gynecological examination every 9 - 1 2 months with a cytological smear! Each cervix carcinoma is preceded by an asymptomatic precursor phase (epithelial dysplasia, premalignant changes); however, carcinoma* in situ and an early invasively growing cervical carcinoma do not produce enough signs to be realized by the patients. Signs and symptoms occur only with a certain size, and especially when the primary tumor ulcerates: irregular bleeding, sero-sanguineous vaginal discharge*, contact bleeding; pain usually does not occur until adjacent organs (bladder, rectum, ureters, pelvic vessels, and nerves) are involved. Because of the extensive supply with lymphatic drainage, metastatic

Cervix carcinoma TNM classification and FIGO stages (short version) UICC

FIGO

Tis carcinoma in situ 0 T1 limited to cervix I T1a micro-invasive la T1b clinically invasive lb T2 extension to vagina (exII cept lower third), parametrium (not pelvic wall) T2a vagina (not lower third) IIa T2b parametrium lib T3 extension to lower third III of vagina/parametrium/ pelvic wall T3a vagina (lower third) Ilia T3b parametrium/pelvic wall 1Mb T4 extension to bladder or IVa rectum, beyond pelvis M1 involvement of distant IVb organs spread occurs quite early into parametrium and pelvic lymph nodes, often with encasement and obstruction of ureters (hydronephrosis, chronic renal failure, and uremia as the most frequent cause of death); hematogenous metastases occur later (liver, lungs, pelvis, vertebral column). Stages: see Table. Caveat: the

Cervix carcinoma: Above: early, still microinvasive carcinoma (left) and invasive large-cell squamous cell carcinoma of the cervix (right) Below: mature, papillary adenocarcinoma (left) and poorly differentiated alveolar adenocarcinoma of the cervical mucosa (right) 44

Chlamydia trachomatis early diagnosis of cervix carcinoma is only possible with regular examinations. Diagnosis: vaginal examination*, colposcopy", diagnostic cytology*, punch* biopsy, diagnostic conization*, fractionated curettage*, histology, computed tomography. Therapy: surgical (esp. Wertheim's operation); local and percutaneous radiation. Cf. exenteration.

Cervix carcinoma: Extensive spread, includes vaginal wall, bladder, and rectum (FIGO stage IV) cervix score: 1. (gyn.) examination with regard to the cervical* factor for the indirect recognition of the time of ovulation. Insler's cervix score considers these four criteria: amount of cervical mucus, its spinnbarkeit (see spinnbarkeit test), ferning*, and the gaping of the os, rated 0-3; also a semiquantitative method to determine estrogenization and thus follicular maturation (see mucus, cervical; fertile days). 2. (obstet.) the evaluation of the transition into active labor with the Bishop score which classifies position, length, consistency, and width of the cervix. cervix uteri: neck of the uterus*, c. 3 cm in length, divided into portio s u p r a v a g i n a l (beginning at the isthmus uteri) and the coneshaped portio vaginalis cervicis protruding into the vagina ('cervix' as commonly referred to) with its lining of layered non-cornified squamous epithelium (ectocervix), analogous to that of the vagina*. The mucous membrane of the cervical canal (endocervix) is composed of a single-layered highly prismatic epithelium, containing folds (plicae palmatae) and branched glands which produce varying cervical mucus*, depending upon the stage of the menstrual cycle. Cf. border, epithelial. cesarean section: abbr. CS; the surgical termination of a pregnancy or delivery by operative opening of the uterus with increased risk for mother and fetus. Types: primary CS: before the onset of labor; indications: absolute disproportion*, placenta* praevia, abruptio* placentae, high-risk pregnancy* with increased fetal jeopardy, previous CS, transverse lie*. Secondary CS: becomes necessary during delivery, e.g. in fetal* distress, relative disproportion, protracted deliveries, impending rupture of the uterus. CS are performed under general or epidural anesthesia with the patient

in a slight left position so as to avoid the development of the inferior*-vena-cava syndrome. Surgical methods: 1. intraperitoneal low transverse CS with an arcuate transverse incision in the lower uterine segment, or as classical CS with a longitudinal incision (increased risk of rupture of the uterus); 2. extraperitoneal (abdominal) CS: opening of the lower uterine segment after dissection from the peritoneum; 3.Porro's CS (cesarean hysterectomy): longitudinal opening in the uterus and delivery of the infant, followed by a supravaginal amputation of the uterus with the placenta (e.g. in rupture of the uterus). A CS can be repeated in the next pregnancy; if needed a sterilization* procedure may be combined with it. Termination of pregnancy* by CS is now only rarely done. An infant born by CS is considered a high-risk newborn*. Cf. anesthetic risk. chancre: an ulcer seen in some venereal diseases. Hard chancre: see syphilis; soft chancre: see chancroid. chancre, mixed: the simultaneous existence of a primary lesion of syphilis* and chancroid*. chemotherapy: see cytostatics. Chiari-Frommel syndrome (Johann Chiari, gynecologist, Vienna, 1817-1874; Richard Frommel, gynecologist Erlangen, 1854-1912): atrophy of the uterus and secondary amenorrhea in prolonged (sometimes for years) lactation*. Symptoms: subjective abdominal and back pain, headaches, psychological disturbances. Etiology/Pathology: the cause of the impaired central and reproductive ovarian function is assumed to be a dysregulation in the diencephalon/hypophysis system, possibly also abnormal adrenal and thyroid function. Diagnosis: increased secretion of prolactin, decreased urinary FSH secretion; basal temperature monophasic. Prognosis: complete recovery is possible; however, amenorrhea may persist. A particular variant is its occurrence due to organic (tumorous) changes without preceding pregnancy: Argonz-Ahumada-Castillo syndrome. childbirth preparation: exercise, breathing techniques, physical and mental relaxation, and esp. the insight into psychosomatic correlates of pregnancy, birth, and postpartum period are said to lessen pain and abnormal deliveries (see also anxiety-tension-pain syndrome). Specific methods were originated by Leboyer and Lamaze. An individualized birth preparation including a successful patientphysician relation should be a paramount objective of all antepartum care. See also Read's method; easing of birth, methods for. Chlamydia: a genus of coccoid bacteria-like microorganisms of the family Chlamydiaceae; obligatory intracellular parasites. They enter the cells by phagocytosis and then multiply by division. Two species are known: Chlamydia trachomatis with several subspecies (serotypes) and Chlamydia psittaci. Chlamydia are now frequently noted in genital infections (see Chlamydia trachomatis). Chlamydia trachomatis: species of Chla-

Chloasma

mydia with several subspecies (serotypes) which are distinctly different in their pathogenicity: serotypes A-C cause trachoma; serotypes D-K are the most prevalent causes of non-gonococcal urethritis and cervicitis*; also of salpingitis*, perihepatitis, epididymitis, inclusion conjunctivitis*, and neonatal pneumonia; serotypes L1-L3 cause lymphogranuloma* inguinale. Morphology: barely visible by light microscopy. Two forms: 0.2-0.4 μηι elemental bodies (infectious, predominantly extracellular) which change into 0.5-0.7 μηι particular or initial bodies (intracellular). The latter form intraplasmic inclusions in the host cell. Culture: does not grow on artificial media, isolation in cell cultures (e.g. McCoy cells); demonstration of inclusions with monoclonal antibodies or chemical stains (e.g. with Lugol's solution or Giemsa stain). It can survive in sepharose-phosphate transport medium at 4 °C for 1-2 days; under different conditions survival is considerably diminished. The organism can be shown directly on a slide with immune fluorescence or enzyme immune assay. Serology: complement fixation reaction is positive only in lymphogranuloma inguinale. In these cases as in chronic and severe infections with serotypes D-K antibodies in the serum can be demonstrated by immune fluorescence. Epidemiology: reservoir in humans, transmission by contact. chloasma (Gr. chloazein to sprout): usually symmetrical, sharply delineated, yellowishbrown patches of irregular shape in the face, esp. on forehead, cheeks, and chin; various causes: hormonal chloasma: melanocyte stimulating hormone (MSH), estrogens, gestagens, cf. chloasma gravidarum; drug-induced chloasma: hydantoin, mesantoin, chlorpromazine, oral contraceptives; cosmetic chloasma: photosensitization by furocoumarins (psoralens, bergapten). chloasma

gravidarum: the

physiologic

hyperpigmentation of the facial skin (see chloasma) which occurs in about two-thirds of pregnant women (mostly in the second month) and regresses usually after delivery; sometimes it may persist for a longer time. It is a hormonal chloasma and thus may be seen in conditions other than pregnancy (ovarian tumors, hormonal contraception, and dysfunctional hormonal regulation). Chlormadinone acetate: 6-chloro-17-hydroxy-pregna-4,6-diene-3,20-dione-acetate; C23H29C104, molecular weight 404.94; orally ac-

46

tive gestagen with antiandrogenic action and derived from 17a-hydroxyprogesterone. Use: for signs of androgenization, for the treatment of menstruation disorders and, in combination with estrogens, for hormonal contraception*; cf. gestagens, antiandrogens. chocolate cyst: an endometrial cyst* in the ovary containing tarry, thickened blood breakdown products; frequently adherent to the adjacent structures. See cysts, ovarian. chorangiomatosis: see placentation disorders. chorioadenoma destruens (Gr. chorion

villous skin; aden gland; Lat. destruens destructive): syn. destructive, invasive hydatidiform mole; chorioepitheliosis. A form of a trophoblast* tumor originating from an intact hydatidiform mole* by the invasion of cyto- and syncytiotrophoblast into the myometrium, frequently destroying it up to the serosal covering of the uterus. The prognosis, however, is much better than that of malignant chorioepithelioma*; metastases are rare (and usually regress spontaneously), and complete remission after local excision is possible. Elevated serum gonadotropin levels indicate remaining tumor tissue. Perforation of the serosa may necessitate a hysterectomy*. chorioamnionitis: inflammatory changes (e.g. granulocytic infiltration) of the placenta and fetal membranes in amniotic* infection syndrome. chorioangioma (Gr. angeion vessel): a capillary hemangioma of the placental villous stroma; stillbirths may be associated with placental chorioangioma. chorioepithelioma, malignant: syn. chor-

ion carcinoma; an extremely malignant growth of extraembryonal fetal cells, a malignant form of a trophoblast* tumor. It usually originates from placental cyto- and syncytiotrophoblast and grows without villous stroma invasively and destructively into blood vessels of the myometrium; therefore a marked bleeding tendency and frequent and early metastatic spread into lungs and vagina. Localization: esp. in the uterus after deliveries, abortions, and particularly hydatidiform mole*; rarely (by contact or metastatic) in tubes, ovaries (also primary, as germ-cell tumor), and extragenital (mediastinum, testes); a special form is the placental-site tumor (derived from the intermediary trophoblast; often a very malignant course). Signs and symptoms: similar to hydatidiform mole; if applicable, symptoms from the distant metastases. Diagnosis: diagnostic curettage*. Histological differentiation from chorioadenoma* destruens may be difficult. Therapy: mostly chemotherapy with methotrexate (five-year survival over 50%). chorioepitheliosis: see chorioadenoma destruens. chorion (Gr. villous skin): middle fetal membrane originating from mesoderm* and trophoblast*; at first completely filled by villi. Ch. villosum: near the end of the second month of gestation the villi bordering the decidua capsularis become atrophic. This part of the ch. turns into the ch. laeve (bald chorion): the

circulation

future fetal membranes*. The villi rooted in the decidua basalis proliferate markedly; this part of the chorion turns into the ch. frondosum: the individual villous stems continue in close apposition with the underlying decidua basalis from which the placenta* originates. The chorion epithelia produce HCG, estrogen, and progesterone. chorion biopsy: also chorion villus biopsy; the removal of trophoblast cells from the chorion frondosum of the placenta with a special catheter under ultrasound guidance or endoscopic view in the 7th to 12th week of pregnancy. Thus, it is an earlier method than amniocentesis* (important when a termination of pregnancy* is considered, because of an embryopathy), but with a higher risk. The approach is transcervical, rarely transabdominal; the cells are examined biochemically and genetically for prenatal diagnosis* of chromosomal and other anomalies. chorion carcinoma: see chorioepithelioma,

malignant

chorionic gonadotropin: see HCG. chorionic thyrotropin: see HCT.

chorista (Gr. choristos separate, sequestrated): syn. germ dispersion, germ dislocation; congenital misplacement of embryonal tissue, e.g. from germinal tissue of adrenal glands into kidney or liver, germinal epidermis in ovary; cf. choristoma. choristoma: dysontogenetic swelling originating from the tumor-like proliferation of misplaced tissue (chorista*); not a real tumor. chromopertubation (Gr. chroma color; Lat. pertubare to inflate): the retrograde filling of the fallopian tubes with dye (e.g. indigo carmine) for the demonstration of tubal patency intraoperatively (transuterine injection) or via pelvioscopy* (vacuum intrauterine probe); cf. hydropertubation, sterility. chromosomes: carriers of genetic information; intensely staining thread- or bowshaped components of the cell nucleus. Consist primarily of DNA molecules and base proteins (histones, etc.). The number of chromosomes is characteristic to species; humans have 23 chromosome pairs (homologous chromosomes), in diploid somatic cells thus 46 chromosomes (see karyogram, Fig.); of these, 22 pairs are known as autosomes, one chromosome pair as heterochromosomes. Both heterochromosomes are the same for females (homogametic sex; karyotype 46, XX), in the male, they are different (heterogametic sex; karyotype 46, XY). Chromosomes are identically doubled by cell division through mitosis*; germ cells originate by reduction division (see meiosis). Cf. karyogram; aberrations, chromosomal. circulation: 1. adult blood circulation: the right atrium receives blood from the venae cavae and conducts it into the right ventricle. From there it flows through the pulmonary artery where the pressure is relatively low to the lungs. In the lungs it takes up oxygen, yields carbon dioxide, returns to the left atrium, and is conducted to the left ventricle. From here it flows through the aorta where the pressure is

Fetal circulation: 1: sup. vena cava; 2: inf. vena cava; 3: duct u s v e n o s u s ; 4 : umbilical vein; 5: uterine vein; 6: placenta; 7: uterine artery; 8: lower extremities; 9: umbilical arteries; 10: intestines; 11: liver; 12: aorta; 13: ductus arteriosus; 14: lung; 15: pulmonary artery; 16: foramen ovale; 17: upperextremities; 18: cranial circulation

high, perfuses the tissues, and returns to the venae cavae. 2. fetal circulation: in the older fetus blood, which has been arterialized in the placenta*, flows to the umbilical vein, thence partly via the ductus venosus, partly via the hepatic circulation to the inferior vena cava and the right atrium. Here the blood stream crosses unmixed with the blood from the superior vena cava. The blood from the inferior vena cava flows through the foramen ovale into the left atrium, then the left ventricle, and the aorta where it splits into two vascular areas: a) via the carotid arteries to the head, and b) via the aorta to the lower half of the fetal body, and the umbilical arteries for return to the placenta. The blood from the superior vena cava flows from the right ventricle to the proximal pulmonary artery, from there to a small extent in47

circumcision, female to the lungs, but mostly via the patent ductus arteriosus into the aorta where it mixes with the arterial blood. The ductus arteriosus and the umbilical vessels obliterate within the first 6 weeks elfter birth, and the foramen ovale closes most of the time (failure to do so is associated with persistent fetal* circulation), and regular pulmonary and systemic circulation is established. Oxygen-sparing mode of fetal circulation: adaptation of the fetal circulation in intrauterine, mostly chronic, oxygen leficiency states (e.g. pre*-eclampsia, postmaturity*). A decreased perfusion of less vital organs (extremities, lungs, intestine) develops; thus decrease in 02-consumption and improved supply of heart, brain, and placenta. Disadvantage: production of lactic acid in poorly perfused organs leading to primary metabolic acidosis*. circumcision, female: see clitoridectomy. circumference: (obst) outer measure of the fetal head (head* circumference); cf. skull measurements. CIS: abbr. for (gyn.) carcinoma* in situ, cleavage: (embryol.) repeated mitotic divisions of the zygote* into increasingly smaller cells (blastomeres*) up to the stage of the morula*. cleft, facial: uni- or bilateral malformations due to lack or inhibition of the fusion of the facial processes (1st to 2nd month). Types: 1. cleft lip (harelip; median or lateral); 2. cleft maxilla; 3. cleft lip and maxilla; 4. cleft palate; 5. cleft lip and palate; 6. (false) cleft median upper lip; 7. oblique facial cleft, from the eye to the upper lip; 8. transverse facial cleft (macrostoma); 9. facial clefts without relation to embryonal fusion (median nasal cleft, etc.). Facial clefts have multifactorial inheritance and are frequently part of malformation syndromes; they can also be caused by amniotic bands*. They are associated with respiratory and feeding problems and speech disorders. climacteric (Gr. climax ladder): the transition from full sexual maturity to old age in women, caused by the cessation of the cyclic ovarian function; the last menstrual period (menopause) occurs in this period (Fig.). Menopause generally occurs between 48 and 52 years, with the mean at 49 years. Climacteric complaints: one-third to two-thirds of all womI I I I I I

y.

^J

*

""—*

^

44 46 48 5 0 - 5 2

54 56 5 8 60 χ

Climacteric:

X age (years); y: relative levels; a: meno-

pause; 1: gonadotropins; 2: estrogens

48

O a

r

nJ Cr l ^

Clomifene

! a

42

en have climacteric complaints requiring treatment. Cause of these complaints is the physiologically decreased production of estrogen (Fig.) and vegetative regulatory disturbances, triggered either directly or from the diencephalon. 1. premenopausal climacteric complaints (c. 6 years before menopause): irregular menses, esp. climacteric bleeding (prolonged bleeding due to persistent follicles*). These dysfunctional hemorrhages may occur to a lesser extent after menopause. Autonomic-psychological disorders also occur in premenopause. 2. postmenopausal climacteric complaints (c. 6 years after menopause): many autonomic and psychological disorders, hot flashes, perspiration, vertigo, palpitation, angina, insomnia, anxiety, decreased energy, mood swings, depression, irritability, forgeliulness. Prolonged bleeding may also occur, but less commonly than in premenopause. Cf. menopausal syndrome. climacterium praecox: see menopause, premature. climax: 1. climacteric*; 2. orgasm*; 3. critical stage of a disease. clitoridectomy: 1. the surgical removal of a clitoris affected by a tumor (e.g. fibroma); 2. so-called female circumcision: in some societies customary removal of the clitoris for the elimination of female sexual sensation. clitoris: female erectile organ, homologous to the corpora cavernosa penis; body formed from both crura clitoridis, which unite to the corpus clitoridis (with glans clitoridis). Located on the anterior end of the labia minora. clitoris, frenulum of: see frenulum clitoridis. clitoris, suspensory ligament of: see ligamentum suspensorium clitoridis. Clomifene (INN-Ε): clomiphene; clomifenum INN-L); diethyl-(2-£p-(ß-chloro-a-phenylstyryl)-phenoxy]-ethyl)amine (IUPAC); CASNo. 911-45-5; C2eH2eClNO; molecular weight 405.98; synthetic, weakly antiestrogenic stil-

bene derivative. Mechanism of action: competitive inhibition of the estrogen receptors in the hypothalamus and the hypophysis, which leads to the induction of ovulation* through the increased secretion of gonadotropins*. Therapeutic use: for ovulation induction* in the anovulatory* cycle; in men Clomifene stimulates spermiogenesis in oligospermia. Cf. stilbenes, Clomifene test. Clomifene test: procedure used for the differentiation of a centrally induced amenor-

colpocleisis rhea* (function test), also for ovulation induction* in the anovulatory cycle. Principle: after the administration of 100 mg of Clomifene* for 5 days the diencephalic estrogen receptors are blocked, which (normally) leads to a compensatory increase in the secretion of LH* and FSH*, and to the stimulation of ovarian (production of estrogens and progesterone*) and generative ovarian function (ovulation*). Assessment: a positive result (induction of ovulation*) suggests an intact hypothalamic*-hypophyseal axis. If the Clomifene test is negative, the partial gonadotropic function of the anterior pituitary lobe (secretion of LH and FSH) can be tested through stimulation with LH-RH; cf. gonadotropin test CMV: abbr. for cytomegalovirus.* coccygeus muscle: see musculus coccygeus. coccyx: os coccygis; vestigial part of the involuted skeletal tail; formed from 3-5 mostly synostotic fused vertebral rudiments, the superior part of which has two small transverse processes (processus transversi) and part of the cranial projecting articular processes (cornua coccygea); usually curved slightly ventral. The filum terminale of the spinal cord is attached to the dorsal surface of the second vertebra. coil: colloquial term for intrauterine contraceptive* devices. coitus (Lat coire to go together): heterosexual genital intercourse with introduction of the penis into the vagina. coitus interruptus: the oldest method of contraception*; during coitus* the penis is withdrawn from the vagina, before ejaculation and sexual intercourse* is continued in another fashion. Disadvantage: low acceptability for both partners; low reliability (Pearl index: c. 25). cold injury syndrome: see hypothermia, coles femininus: see clitoris, colostrum: the initial milk produced during pregnancy (from the 6th week on) and secreted during the first 3-5 days after delivery. It is difColostrum Average composition and energy content per 100 ml Energy Protein Casein Lactalbumin Lactoglobulin Fat Carbohydrates Minerals Vitamin A Vitamin C

281 kJ (67 kcal) 2.3 g (1.5-9.0) 1.0 g 0.8 g 0.5 g 3.0 g 4.0 g 0.3 g c. 0.16 g c. 0.007 g

ferent from mature breast* milk by a higher content of proteins, minerals, vitamins A and C, with about equal carbohydrate and slightly lower fat content; in addition it contains the so-called colostrum bodies (Donne's corpus-

cules, fat-laden leukocytes). The yellow color of colostrum is caused by carotene. Composition: see Table. colpitis (Gr. kolpos hollow): syn. vaginitis; acute or chronic inflammation of the vagina*, often as vulvovaginitis*. Etiology: usually invasion of the vagina with exogenous organisms due to lack of estrogen stimulation of the vaginal epithelium, atrophy (physiological in childhood and postmenopause, changes in the acid vaginal environment toward an alkaline pH,

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Colpitis: Cytological findings of inflammation: many bacteria (esp. on squamous epithelial cells) and inflammatory cells and direct interference with the normal vaginal flora* (also by antibiotics and sulfonamides); causative organisms: Trichomonas vaginalis (see trichomoniasis), Candida albicans (see Candida vulvovaginitis), rarely staphylococci, E. coli, Gardnerella vaginalis, Neisseria gonorrhoeae (gonorrheal vulvovaginitis in young girls and older women); in non-specific colpitis the smear shows a mixed flora. Signs and symptoms: vaginal discharge*, pruritus vulvae, burning sensation, difficult urination. Types: 1. simple colpitis: diffuse erythema and smooth swelling of the vaginal wall; 2. granular colpitis: diffuse or focal erythema with many flat, red nodules of varying size (leukocyte infiltrates) which turn into small ulcers; after healing gray-brown spots remain. A particular manifestation is senile colpitis, often with an acute course, due to age-related atrophy of the vaginal epithelium (estrogen deficiency) with loss of the protective acidity, usually triggered by the ascent of organisms from the skin; an abacterial inflammation is rare.

Each colpitis in an older woman should suggest a carcinoma. colpo-: relating to the vagina, colpocele: a prolapse of the vagina in descensus* uteri. colpoceliotomy: the surgical opening of the peritoneum from a vaginal approach. colpocleisis: the surgical closure of the vagina. 49

colpocytology colpocytology: evaluation of the epithelial cells obtained from the lateral vaginal wall. Growth and decay of vaginal epithelial cells are regulated by estrogen and progesterone; during the menstrual* cycle the cells change their shape and staining characteristics. Follicular phase: large, separate cells with initially vacuolar, later small pyknotic nucleus; acidophilic staining characteristic. Corpus luteum phase: characteristic mass shedding of the cells with typical clumping, increased folding and crimping. Mostly intermediate cells with vacuolar nucleus and basophilic cytoplasm. Evaluation: see cytology, diagnostic. Cf. karyopyknotic index, colposcopy. colpography: the radiographic imaging of the vagina with contrast media. colpoperineoplasty: also colpoperineorrhaphy; the surgical tightening of the pelvic floor at the posterior vaginal circumference in descensus* uteri. colpopoiesis: the formation of a vagina, e.g. in gynatresia* or sex* change operations; 1. by using the intestine, e.g. sigmoid vagina; 2. by lining the vagina with transplanted peritoneum or epidermis (penis skin in sex change procedures). colporrhaphy (Gr. rhaphe a seam): the surgical tightening and supporting of the anterior or posterior vaginal wall in vaginal descenf t 1 »

colporrhexis: complete or partial tearing of the vagina from the uterus in the vaginal vault, e.g. during delivery and (rarely) as coital trauma; see also laceration, vaginal. colposcopy: the examination of cervix and vaginal wall epithelium under 10-30-fold magnification with a colposcope, esp. of the epithelial border*; often as routine part of a vaginal examination*. The normal smooth (iodine-positive) squamous epithelium is termed native. Cervical ectopia* and transition* zone are physiol. findings; cervical erosion* and erythroplakia* require clarification. Suspicious findings (so-called matrix areas for carcinoma, iodine-negative) are: cervical leuIn over 90% a cervix carcinoma begins in the area of the squamous epithelium over the lowest glands of the cervical mucosa. koplakia*, mosaic* pattern, punctation* and an atypical transition zone; they are considered a premalignant condition for cervix* carcinoma and require a biopsy* (diagnostic conization*, or punch* biopsy) and histology (carcinoma* in situ?), as well as regular followup examinations. A complementary method is CrtUi ΙΙΛ«'«* ΪΛ^ΐν>Λ +Λίΐ4· Γ^ίrtirfrtlArttr/Ii

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Transverse lie: The five signs of transverse lie in the abdominal examination: 1. no presenting part; 2. wide abdomen; 3. fundal height smaller than expected; 4. large parts palpable laterally with the head on one side and the breech on the other; 5. heart tones best heard in the periumbilical area

Stages of sexual development in women

Age

> 6 yrs. > 8 yrs. >12 yrs. >15 yrs. >16 yrs. > 18 yrs. at 25 yrs. >43 yrs. approx. 49 yrs. > 50 yrs. >65 yrs.

ligamentum cardinale uteri: see ligamentum latum uteri, retinacula uteri. ligamentum genitoinguinale (Lat. ligamentum band): (embryol.) caudal mesonephric duct or reproductive cell band; phylogenetic

Lipschütz's ulcer anlage of the male gubernaculum testis or the female lig. ovarii proprium, and the lig. teres uteri. ligamentum latum uteri: broad ligament of the uterus* (see Fig.); paired peritoneal duplication with a tendency to ventral direction because of the anteflexion position of the uterus, joining in a sheet-like fashion the side edges of the uterus with the pelvic lateral walls. Caudally, it forms a continuum with the subperito-

neal pelvic tissue (parametrium*) widening to the lig. cardinale uteri (see retinacula uteri, Fig.), carrying the blood vessels (arteria* uterina). In a fold of its anterior surface the ligamentum* teres uteri, coming from the uterotubal* angle, extends in the direction of the inguinal canal. From its dorsal aspect, it opens in a secondary duplication to the ovaries, the mesovarium. The free edge of the mesovarium extending from the extremitas uterina ovarii to the utero-tubal angle is compressed to the ligamentum* ovarii proprium, while its lateral border, passing from the extremitas uterina ovarii to the infundibulum tubae uterinae, contains the fimbria* ovarica. The part of the ligamentum latum uteri lying superior to the fold of the mesovarium holds the tuba uterina in its free upper border, which functions as mesosalpinx. Its lateral, tubeless section extends upwards as the lig. suspensorium ovarii to the lateral pelvic walls, and carries the arteria* ovarica and vena ovarica with it. Mesosalpinx and the dorsally located mesovarium thus are cranial branches of the lig. latum uteri; the section inferior to this bifurcation is the only actual mesentery of the uterus (mesometrium) which continues into its peritoneal cover (perimetrium). ligamentum ovarii proprium: ovarian band, originating from the caudal gonadal fold. Extremitas uterina ovarii < > uterotubal* angle; in the dorsal wall of the ligamentum* latum uteri. ligamentum pubicum superius: Cooper's ligament; it passes transversely along the superior edge of the symphysis. ligamentum pubovesicale: in the male: lig. puboprostaticum; belonging to the retinacula* uteri, paired ancillary fibres of the fascia diaphragmatis pelvis superior, extending from the dorsal surface of the os pubis to the

bladder or prostate; cf. fascia pelvis. ligamentum sacrouterinum: see Douglas' pouch. ligamentum suspensorium clitoridis: suspensory band of the clitoris; of elastic connective tissue; symphysis < > dorsal side of the clitoris. ligamentum suspensorium mammae: reinforcement of the fascia* pectoralis superficialis, to which the mammary gland is attached moveably over the fascia of the pectoralis muscle; in addition, connective tissue threads (retinacula) penetrate the breasts from the cutis to the fascia and compartmentalize the adipose tissue. The nature of the connective tissue structure and the degree to which it is filled with fat tissue determine the firmness of the breasts. ligamentum suspensorium ovarii: peritoneal fold from the extremitas tubaria of the ovaries upwards to the lateral pelvic walls. It contains the arteria* ovarica and v. ovarica. Phylogenetically developed from the cranial gonadal band. Cf. ligamentum latum uteri. ligamentum teres uteri: courses from uterotubal* angle in the anterior wall of the ligamentum* latum uteri through the inguinal canal into the connective tissue of the labia majora. Phylogenetically originating from the caudal gonadal band. Cf. retinacula uteri (Fig.). ligamentum transversum perinei: firm connective tissue sheet on the anterior border of the diaphragma urogenitale, spread within the angle of the os pubis; formed by the sheets of the fascia diaphragmatis urogenitalis superior and inferior. Cf. pelvic floor. Liley zones: see spectrophotometry, amniotic-fluid. linea arcuata: also linea arcuata of Douglas; inferior, upward-directed convexity, archshaped edge of the dorsal sheet of the aponeurosis of the musculus obliquus internus abdominis, about five centimetres below the umbilicus. For the most part without distinctive borders: area arcuata (Lanz). Here the aponeurosis of the musculus transversus abdominis, which helps to form cranially the posterior layer of the rectal sheath, turns into the anterior layer of the rectal sheath. Thus, the dorsal surface of the musculus rectus abdominis is separated caudally from the linea arcuata from the abdominal cavity only through the fascia transversalis and the peritoneum. linea arcuata o s s i s ilii: oblique line running from superior dorsal os ilium to inferior ventral os ilium at the border of the large and small pelvis; see pelvis. linea fusca: 1. deeply pigmented skin area over the linea alba in pregnancy; 2. lines of brown discoloration of the forehead parallel to the hairline, especially in epilepsy or after encephalitis. linea glutaea anterior, inferior, posterior: flat bony crest between the sites of origin of the mm. glutaei on the outer surface (facies glutaea) of the iliac wing, linea terminalis: see pelvis. Lipschütz's ulcer: see ulcus vulvae acutum of Lipschütz. 141

Listeria

Listeria (Joseph Lister, surgeon, London, 1827-1912): genus of gram positive, peritrichally ciliated, mobile bacterial rods of the family Corynebacteriaceae; of special medical importance is Listeria monocytogenes. listeria agglutination: serological reaction to determine agglutination in the serum of patients suspected to have listeriosis* (Widal's reaction; > 1:320 suspicious), or for the identification of suspicious bacterial colonies with specific agglutinizing immune sera (Gruber's reaction). Listeria m o n o c y t o g e n e s : previously Lis-

terella or Corynebacterium infantisepticum; the only species of the genus Listeria (different serotypes) which is a pathogen for humans. Morphology: see Listeria. Infection in humans can show a variety of clinical manifestations; see listeriosis. listeriosis: syn. granulomatosis infantiseptica; zoonosis (cow, sheep, goat, pig, poultry, rodents), rarely transmitted to humans. Organism: Listeria* monocytogenes. Manifestation: 1. in adults frequently asymptomatic; with special disposition (convalescence, pregnancy), symptomatology may resemble a cold, mild meningoencephalitis, mononucleosis, localized as keratoconjunctivitis, or, in pregnancy, frequently as pyelonephritis or endometritis. 2. much more frequent and dangerous is transplacental transfer of the organism from the infected pregnant woman to the fetus in the last weeks of pregnancy, resulting in fetopathy* with hematogenous spread of the organism throughout the fetal body (sepsis), which

blood, CSF of infants; occasionally in (discolored) amniotid fluid, urine, blood, lochia, or curettings from the mother. Clinical suspicion can be confirmed by serology (agglutination, complement fixation test). High mortality (approximately 50%), frequently late sequelae (mental retardation). lisuride: 3-(10,10a-didehydro-7-methyl-9aergolinyl)-l,l-diethylurea; C20H2eN4O; molecular weight 338.46; dopamine agonist which by binding to the dopamine receptors in the hypophysis inhibits the release of prolactin (prolactin*-inhibitor); also has a high affinity to serotonin receptors. Therapeutic use: for the inhibition of lactation, milk retention, mastitis, galactorrhea, prolactin-induced amenorrhea and infertility, for microprolactinoma, acromegaly (reduces the STH-secretion from hypophyseal tumors), Parkinson's syndrome. lithotomy position: position of the patient on the back with the legs spread and flexed at hip and knee joints (buttocks are placed at the

mother

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Listeriosis: Possible routes of infection of congenital listeriosis

can result in stillbirth or premature delivery. Surviving neonates show the following signs due to the invasion of the body with organisms and the granulomatous tissue reaction in the skin and internal organs (bacterial emboli; so-called granulomatosis infantiseptica): papulous efflorescence of the skin, meningoencephalitis with meningism (seizures, vomiting, stupor, dyspnea or apnea), abnormal CSF findings, hepatosplenomegaly with or without jaundice. Diagnosis: demonstration of bacteria in stool, urine, nose or throat, 142

edge of the table); used for diagnostic and therapeutic maneuvers in the vaginal or anorectal area. Litzmann's obliquity (Karl Litzmann, gynecologist, Kiel, 1815-1890): (obst.) posterior asynclitism, mild degree of posterior parietal bone presentation, a rare form of asynclitism* with risk of delayed cervical dilatation and entrapment of the cervical lip; see also asynclitism, anterior. lobus glandulae mammariae:

glandular

lobe of the female breast; 15-20 in each mamma, made up of large and small lobes (lobuli glandulae mammariae); cf. ductus lactiferi. lochia (Gr. locheia cleansing of the postpartum woman): in the first 3 to 4 days sanguineous (lochia cruenta or rubra), then for several days brown (lochia fuscia), then yellow (lochia flava), after three weeks postpartum white (lochia alba); in general, healing is complete 6 weeks postpartum. lochiometra: lochial retention in the uterus; lochia is fetid (offensive odor); usually secondary to infection. lordosis: compensatory lordosis is normal in pregnancy to correct the forward shift of the center of gravity by the pregnant uterus.

Lyell's syndrome

Lovset's maneuver (Jörgen Lovset, gynecologist, Bergen): method to release the arms in breech* presentation. Procedure: 1. the baby is grasped at the pelvis, and the body is rotated 180 degrees under continuous downward traction. The anteriorized arm usually

lues: s y n . s y p h i l i s * .

lunar months: months with 28 days; pregnancy is divided into ten lunar months (280 days: calculated from first day of the last menstrual period), which is the equivalent of approximately nine calendar months. lung development, fetal: d e v e l o p m e n t of

lung parenchyma from the branching bronchial buds (5-13 weeks pregnancy) over the intermediate stage to the alveoli stage (approximately 24-26 weeks); in addition to parenchyma maturation, fetal lung development also includes cell differentiation into several distinctly different cell types (epithelial cells of the bronchi, pneumocytes type I and II) and biochemical maturation (production of surface active substances, surfactant*, anti-atelectasis factor); see also lung maturity tests, prenatal. lung maturation, induced: p r e n a t a l Levset's m a n e u v e r t o release the arms: S t e p 1 (left); step 2 (right)

drops out spontaneously (Fig.). 2. a reverse 180 degree rotation of the fetal body with the same maneuver will anteriorize the posterior arm, which again frequently is released spontaneously. Subsequently the Mauriceau*Veit-Smellie maneuver is used to deliver the head. low back pain: general term for pain in the central and lower lumbar region; caused by excessive strain or fatigue of the m. erector trunci (asthenic constitution, neurasthenia), static changes (pregnancy*, excessively high heels), lumbago, sciatica, pelvic vein varicocities (pain increased in supine position), gynecological disorders (abnormal uterine position, parametritis*, ovarian tumors*), orthopedic disorders, specifically of the spine (spondylosis, tumors). Unilateral low back pain is typical for proctitis, sigmoiditis, dysmenorrhea*, parametritis posterior. Low back pain is rarely caused by gynecological disorders. low-birth-weight infant: s e e i n f a n t , l o w -

birth-weight.

lower abdominal pain, functional:

ma-

ternal medical treatment to stimulate surfactant* synthesis in fetuses with suspected lung immaturity (see lung maturity tests, prenatal); most important medication: glucocorticoids, e.g. dexamethasone (parenteral treatment).

see

abdominal complaints, functional. L-S ratio: abbr. for lecithin/sphingomyelin ratio in amniotic fluid; technique for prenatal lung* maturity tests; also as test for lung maturity in the newborn. LTH: abbr. for luteotropic hormone, older term for lactotropic hormone, syn. prolactin*. lubrication: transudation* of mucoid substance through the vaginal mucosa during the excitation phase of sexual intercourse ; cf. sexual response. lubrication deficiency: i n a d e q u a t e l u b r i -

cation* of the vagina; cf. dysfunctions, sexual.

Lucey-Driscoll syndrome: s y n . t e m p o r a r y

familial hyperbilirubinemia of the newborn; specific type of icterus* neonatorum, due to the presence of an inhibitor (steroid?) of the glucuronyl transferase system in maternal and neonatal serum. Within 48 hours of birth, severe jaundice develops in the newborn (no indication of hemolysis).

lung maturity tests, prenatal: t e c h n i q u e s

for the determination of intrauterine fetal lung maturity from amniotic fluid; 1· chemical methods to determine the concentration of phospholipids; methods: determination of the ratio between concentrations of lecithin and sphingomyelin in the amniotic fluid (so-called L-S ratio) and the determination of the lecithin concentration. L-S ratio values above 2.0 and lecithin values above 4.4 μπιοΐ/ΐ (3.0 mg/dl) indicate lung maturity. 2, a physical method for the determination of surface tension is the shake test (Clements' test): ethanol is added to amniotic fluid in several dilutions, and after shaking the formation of stable bubbles on the surface of the amniotic fluid is observed. Indication: threatening premature delivery, induction of labor for maternal and fetal compromise, before termination of long-term tocolysis for preterm labor. Cf. hyaline membrane disease; lung maturation, induced. luteohormone: see progesterone, gestagens. luteoma: neoplasm of the ovarium* consisting of luteinized granulosa or theca cells; may occur as true neoplasm mainly in postmenopause with resulting endocrine effects or as tumor-like growth in pregnancy; malignant changes are extremely rare. See granulosa-cell tumor, theca-cell tumor. Lyell's syndrome (Alan Lyell, dermatologist, Aberdeen): syn. toxic epidermal necrolysis (TEN), epidermolysis acuta combustiformis, scalded skin syndrome; extensive bullous separation (necrolysis) of the epidermis which appears greyish-white, scalded. Signs: painful erosions; frequently hyperpigmentation after healing. Oral, nasal, genital mucous membranes and conjunctiva (risk of blindness) can be affected. Etiological differentiation: 1. induction by medication: allergic-toxic reaction to drugs, usually in adults, rarely in children. Subepidermal bullae formation with necrosis (Nikolski's sign negative). Treatment with high-dose corticosteroids. 2. staphylogenous: 143

lymphangitis carcinomatosa

toxic effect of toxin (epidermolysin, exfoliatin) produced by Staphylococcus aureus group II, almost exclusively seen in neonates. Intraepidermal bullae formation without necrosis (Nikolski's sign positive). Anamnestically or on examination usually a purulent infection is noted (otitis media, rhinitis, pharyngitis). Satisfactory prognosis when treated with betalactamase antibiotics. The staphylogenous Lyell's syndrome in the newborn and infant corresponds to toxic epidermal necrolysis*.

lymph nodes, m a m m a r y : nodi l y m p h a t i c i

pectorales; see lymph nodes, axillary (Fig.). lymph nodes, pectoral: Sorgius

lymph

node group; the nodi lymphatici pectorales on the free border of the m. pectoralis major (see lymph nodes, axillary, Fig.) receive most of the lymph of the breast. Breast carcinoma metastasizes early into these lymph nodes. lymph nodes, pelvic: r e g i o n s of c o n f l u e n c e

and drainage: see Fig.; important in malignant tumors of the female genitalia.

lymphangitis carcinomatosa (Gr. l y m p h a

water): the widespread growth of carcinoma in the lymphatics, recognizable macroscopically as fine white net-like pattern, corresponding to the course of the lymph vessels. lymphatic drainage: type of effleurage or stroking massage to remove lymphedema (e.g. arm edema after mastectomy in breast* carcinoma); stroking with the fingertips over the skin in the direction of the lymph channels. lymphedema: pale, doughy, mildly pitting, non-tender swelling due to obstruction of the lymph drainage; arm edema was a common complication after radical mastectomy for breast* carcinoma. Treatment of arm edema is difficult and lengthy, and consists of manual lymphatic* drainage supported by compression bandages. Cf. Stewart-Treves syndrome. lymph nodes (Lat. nodis knot): nodi lymphatici; of particular importance in gynecology are pectoral and axillary lymph* nodes, as well as pelvic lymph* nodes. lymph nodes, axillary: n o d i

lymphatici

axillares; regions of confluence and drainage: see Fig. In gynecology of particular importance in breast* carcinoma. Cf. lymphedema.

1, 2, 3: nil. ( = nodi lymphatici) iliaci communes, interni, externi;4: nil. glutaei superiores; 5: nil. interiliaci; 6: nil. glutaei inferiores; 7: nl. ( = nodus lymphaticus) parauterinus; 8: nil. inguinales superficiales; 9: nil. lumbales; 10: nil. subaortici; 11: nil. sacrales; a: ureter; b: fallopian tube; c: rectum; d: uterus;e: vagina

lymphogranuloma

Axillary lymph nodes: 1: nil. ( = nodi lymphatici) axillares laterales; 2; nil. axillares subscapulares; 3: nl. ( = nodus lymphaticus) thoracoepigastricus; 4 u. 5: nil. axillares pectorales (4: Sorgius group); 6: nl. parasternalis; 7: nil. axillares centrales; 8: nil. axillares apicales; 9: nil. s u p r a c l a v i c u l a r s . Superficial lymph nodes: black, deep: stippied. Arrows show the direction of flow.

144

inguinale:

syn.

lym-

phopathia venerea, also lymphogranuloma venereum, Durand-Nicolas-Favre disease; rare venereal disease associated with characteristic lymphadenitis, not recognized as independent disease until 1913, distributed throughout the world, mainly in the tropics. Incubation period: 2-6 weeks, occasionally several months after intercourse with the carrier. Organism: Chlamydia* trachomatis (serotypes L1-L3). Signs: 1. localized: a) primary lesion: initially small vesicle (papula), with subsequent superficial erosion or ulceration, red, smooth, moist base and clearly demarkated margins, surrounding area not infiltrated. Location in women usually the medial aspect of labia, introitus, fourchette; in men sulcus coronarius, inside the prepuce. Usually rapid healing of the primary lesion within 10 to 14 days.

lynestrenol

Variable interval between primary lesion and swelling of the lymph nodes; frequently synchronous appearance of primary lesion and lymph node swelling, even the later appearance of the former has been observed. Due to minimal symptomatology, the primary lesion is frequently dismissed, and only the lymph node symptoms lead the patient to seek medical attention, b) lymph node symptoms: usually unilateral involvement of the lymph nodes of the groin. Initially a small mobile swelling (bubo) which rapidly increases in size and tenderness and can reach the size of a chicken egg or fist; several initially separable nodes fuse, include the overlying skin, liquify, and form chronic fistulae with secretion of viscous pus which itself causes eczema and pyoderma. Healing after several weeks results in the formation of characteristic small retracted scars. A similar process is possible in the pelvic lymph nodes. In approximately half of the cases, the enlarged lymph nodes can be palpated abdominally, medial to the upper part of the ilium. Occasionally, the anorectal lymph nodes can be palpated laterally and posterior-

ly through the rectum. The involvement of these pelvic lymph nodes is of decisive importance for the sequelae (elephantiasis genitoanorectalis). 2. general symptoms: from the mildest and insignificant symptoms to severe sepsis. Skin manifestations: erythema exudativum and erythema nodosum. Diagnosis: material: vesicular contents of the primary lesion, lymph node biopsy, bubo-pus; laboratory techniques: see Chlamydia trachomatis; antibody detection and patient serum by complement fixation test and immunofluorescence test (IFT). Differential diagnosis: mainly syphilis, chancroid, plague, tularemia, tuberculosis, mycosis, malignancy (including lymphogranulomatosis). Therapy: tetracycline or sulfonamide. lynestrenol (INN-Ε): lynestrenolum (INNL), 17a-ethinyl-4-estren-17ß-ol (IUPAC); CAS-No. 52-76-6; C^H^O; molecular weight 284.42; gestagen derived from 19-nortestosterone. Use: in combination with an estrogen or alone (minipill*) for hormonal contraception*, therapeutically in endometriosis, dysmenorrhea, dysfunctional bleeding; cf. gestagens.

145

Μ

McCune-Albright syndrome (Fuller Albright, physician, Boston, born 1900): syn. Albright-McCune-Sternberg syndrome, Albright's syndrome; combination of mono- or polyostotic fibrous dysplasia*, irregularly bordered ("geographic") cafe-au-lait-colored skin pigmentation (may occur in the region of the affected bones), and in girls precocious puberty* (menarche may occur between the fifth and eighth year of life); gynecotropia. Normal sexual development in boys. May be associated with diplopia (affected bone in the orbits may cause paralysis of the eye muscles), cataract, anomalies of the pupils. Etiology/ Pathogenesis: not hereditary, constitutional disturbance of unknown etiology; in the history frequently pronounced jaundice of the newborn. Diagnosis: (chem.) elevation of serum phosphatase; the values for calcium and phosphate in the serum, as well as the excretion of hormone metabolites in the urine, are usually normal. A combination of McCune-Albright syndrome with hyperthyroidism, exophthalmos, and phosphate diabetes has been observed. M c D o n a l d ' s operation: see cerclage, macula gonorrhoeica: reddening of the orifices of Bartholin's* and other glands of the vestibulum vaginae in advanced stages of acute gonorrhea*. male mortality, increased: in general, the rates of stillbirth and infant* mortality are increased in boys compared to girls. In the past few years, this has been noted in the F.R.G. only for low-birth-weight neonates (approximately % increased risk in boys). malformations, anorectal: abnormal development of the rectum at the time of differentiation of the primitive cloaca: anal and/or rectal atresia, frequently combined with fistula formation or anomalies of other organs (especially the urogenital system). For surgical reasons (early surgery) divided into high (above levator), intermediate, and low (translevatoric) anomalies. Signs: absent meconium passage (differential diagnosis: meconium plug) and inability to pass a rectal tube. malformation, congenital: also congenital abnormality; persisting abnormality of single or several organs due to a disturbed intrauterine development during organogenesis. Some, possibly the majority of these developmental disorders are caused by endogenous factors (spontaneous derailment of development, spontaneous mutation* of the gametes involved, or mutations in preceding generations of gametes). Another, probably small section is attributed to exogenous causes (drugs,

A n o r e c t a l malformations: A n a l atresia in a male neonate

chemical substances, viral infections, ionizing radiation; cf. embryotoxicity, thalidomide embryopathy, rubella embryopathy). Quite frequently, it is not possible to distinguish between genetic malformations caused by endogenous and those caused by exogenous factors Congenital malformations Incidence (data from different countries) Type of anomaly

Indicence per 1000

Total Anencephaly Spina bifida Hydrocephaly Cardiac anomalies Talipes Polydactyly Dislocation of the hip Cleft lip/palate

10-40 0.6-4.6 0.2-4.1 0.5-1 8 1.0-9.0 0.6-3.95 0.6-2.4 0.7-3.4 0.8-3.0

The above numbers show a significant spread which is partially due to ethnic and other differences in the true incidence. On the other hand, it also reflects deficiencies in documentation which emphasizes the need for a s y s tematic basic registry. 147

malformations, uterine (see phenocopy). Defects in internal organs (congenital cardiac anomalies, renal malformations, etc.) can be recognized at birth only in case of distinct functional sequelae. Frequently congenital malformations occur in typical combinations in various organs (socalled malformation syndromes). malformations, uterine: various degrees of duplication of the uterus due to incomplete fu-

5

6

7

8

Uterine malformations: 1: uterus didelphys with duplication of vagina; 2: u. bicornis duplex (occurs with or without vaginal duplication); 3: u. bicornis unicollis; 4: u. arcuatus with mild indentation; 5: u. septus duplex with vaginal septum; 6: u. septus duplex; 7: u. subseptus; 8: u. biforis sion of the müllerian ducts (see Fig.); cf. müllerian duct malformations, vaginal: arrest of development of the vagina*, occurring in isolation, or with anomalies of the uterus (uterine malformations*) and/or urinary tract Types: 1. aplasia vaginae (vaginal agenesis*); see Rokitansky-Küster-Hauser syndrome; 2. atresia vaginae; lack of canalization, usually involving the proximal part of the vagina; 3. vagina septa (complete) or subsepta (incomplete septation) due to incomplete fusion of the müllerian

ducts; longitudinal and transverse septation is possible. A median septum can cause coital difficulties, while lateral septae may remain undiagnosed (can cause birth obstruction!); coitus, pregnancy, and vaginal delivery are usually possible in vagina subsepta. malformation syndromes: syn. polyphenia; characteristic combination of congenital anomalies involving multiple organ systems; frequently already recognizable in neonates; see malformations, congenital; cf. diseases, genetic. malignancies, multiple primary: concurrent existence of several primary malignancies, e.g. ovarian or breast carcinoma in patients with endometrial carcinoma (seen in approximately 10% of cases). malposition: any fetal position* other than longitudinal lie; specifically oblique or transverse lie, as well as breech presentation, which, although a longitudinal lie, is considered an abnormal presentation. mamilla: nipple*; cf. mamma, mamilliplasty: operation to maintain or reconstruct the areola mammae and mamilla, e.g. after mastectomy*. Besides operations which maintain the mamilla (occasionally with temporary autotransplantation of mamilla and areola mammae into the groin and re-implantation), the following techniques are used: 1. transplantation of parts of the contralateral mamilla (occasionally also parts of the areola); 2. transplantation of more pigmented skin from other regions: harvesting from the inner thigh, eyelids, or labia majora for the reconstruction of the areola mammae, from the labia minora or ear lobe for the mamilla (see Fig.). Contralateral differences in pigmenta-

Mamilliplasty: Results of reconstruction of the areola m a m m a e and nipple

Vaginal malformations: Vaginal septum 148

tion can be corrected by tattoos; a significant decrease in sensitivity is to be expected. mamma (Lat. female breast): mammary gland, glandula lactifera; secondary sexual characteristic of the woman. The mamma consists of glandular tissue, fibrous tissue, and an individually variable amount of adipose tissue; branching duct system with terminal glandular acini; during lactation* they are always alveolar with apocrine secretion. Stages of breast development (Tanner* stages): see Fig. Estrogens* and progesterone* induce

mammoplasty

muscle fascia

adipose tissue (black)

areola mammae

amined. Mammographie signs indicative of carcinoma: tumor shadowing, peritumorous halo, microcalcifications*, spicules, vascular breaks and variable vascular diameters, nipple retraction, skin thickening, and difference in the shape of the breast on right/left comparison. Caveat: mammography can be normal with medullary or tubular carcinomas. Occasionally, it is impossible to differentiate between benign and malignant changes (histological diagnosis mandatory!). Cf. xeromammography, galactography, thermography.

papillae ductus lactifen

glandular nssue (liglitl

sinus lactifen

Mamma cycle-dependent changes in the glandular tissue with sometimes painful swelling and formation of nodes which reach their peak near the end of the menstrual cycle; cf. nipple.

Annual mammography is indicated in all women at high1 risk: 1. women afüer treatment for carcinoma of the breast 2. women with1 a family MMwy of carcinoma of the breast 3. women with mastopathy The technique serves as a screening method. Aim:: recopnüm of occult breast carcinoma. mammoplasty: operation to create a normal breast shape (eumastia*), to reconstruct or to satisfy aesthetic needs; many methods: 1. mammoplasty without implant: e.g. mastopexia in mastoptosis*; reduction mammoplasty in hypermastia*; transplantation of endogenous fat tissue to create a so-called small fat breast; various sliding or rotating flap procedures (e.g. a flap from the abdominal wall

The most favorable time for examination of the breasts is the week after completion of menstruation.

: ••fii• ;: ·· n^^p^^^H :;ifS3§S •ftfÄ

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1

2

3

H

4

Mamma: D e v e l o p m e n t a l stages ( 1 - 5 )

mammary gland: see corpus mammae, mammography: (radiol.) radiological examination of the female breast with a special technique (usually grid technique), specifically to confirm and localize abnormal palpatory findings, to evaluate a nipple discharge or bleeding mamma, to monitor patients at risk, and to screen normal patients. Aim: to recognize premalignant stages, atypical proliferating mastopathy*, and occult breast* carcinoma. Technique: craniocaudal and mediolateral (profile) views of the mammae, special view of the axilla; since there is tremendous individual tissue variation, both sides must always be ex-

Mammoplasty: A e s t h e t i c a u g m e n t a t i o n plasty by p r e p e c toral p l a c e m e n t of t h e implant t h r o u g h an axillary incision

149

mammorenal syndromes or back and formation of a new submammary skin fold) as a reconstructive procedure. 2. use of implants for mammoplasty: for reconstruction after mastectomy*, as well as augmentation in hypomastia*; the most popular implant is a silicone prosthesis (see Fig.), occasionally a skin expander is used; cf. breast prosthesis. Mammoplasty is supplemented by procedures to reconstruct the mamilla and areola; see mamilliplasty. mammorenal syndromes: comprehensive term for various congenital syndromes with anomalies of breast or nipple and kidneys; the more than random combination of mamilla and mamma anomalies with renal dysplasia

cases, exposure to unfavorable metabolic conditions (infection, excessive leucine intake) can produce temporary, however, occasionally also lethal cerebral manifestations with amino- and ketoaciduria. Signs: mental retardation, poor feeding, dyspnea, myoclonus. The name is derived from the characteristic odor (burned sugar), probably due to excretion of alphahydroxybutyric acid (metabolite of isoleucine). margo liber ovarii (Lat. margo border): the free border of the ovary, opposite the mesovarium, margo* mesovaricus. margo mesovaricus: the ovarian border attached to the mesovarium*, opposite the free edge of the (intraperitoneally located) ovarium*; cf. hilus ovarii. mariscae (Fr. marisque fig): anal folds; permanent anal skin folds, benign, residual after thrombosed hemorrhoids (see Fig.). Unlike

(fi ft)

Mammorenal syndromes: Asymmetrical presence of polythelia or polymastia indicates the side on which the renal anomaly is located.

indicates a yet unknown, common dysontogenesis. According to the number of mamillae (medial or along the medioclavicular line) and differences between each other, the mammorenal syndromes can be differentiated as follows: 1. syndrome of mammorenal pleonasm: bi- or unilateral polythelia* or polymastia* with homo- or bilateral double kidneys. 2. excessively wide intermamillary distance and bilateral renal hypoplasia (Fleischer's* syndrome); 3. unilateral mamilla aplasia and homolateral renal hypoplasia or renal aplasia (Poland's* syndrome); 4. mammorenal dysplasia in chromosome anomalies (e.g. in Turner's* syndrome a combination of excessively widely spaced nipples and horseshoe kidneys is possible). maple syrup disease: branched-chain-decarboxylase deficiency: metabolic anomaly with recessive inheritance, due to lack of the enzyme branched-chain-aminoacid-decarboxylase, resulting in failure to metabolize the three branched-chain-aminoacids leucine, isoleucine, and valine. The blood, CSF, and urine levels of these aminoacids are greatly increased. In addition, toxic intermediate metabolites (hydroxyacids) are produced which characterize the clinical picture of severe toxic illness of the neonate, usually with rapid, frequently lethal course. Onset of the illness usually after the fourth to sixth day of life with signs of metabolic encephalopathy (poor feeding, apathy, seizures, dyspnea). In atypical 150

Mariscae hemorrhoids, filling does not occur with increased abdominal pressure. Large mariscae can cause chronic anal eczema; can be removed with electrocautery. Marshall-Bonney test: see Bonney test. Marshall- Marchetti- Krantz operation: technique of colposuspension* described in 1949 to treat female stress incontinence: elevation/fixation of the urethra by attaching the paraurethral/vaginal tissue to the periosteum of the symphysis pubis. Complication: periostitis ossis pubis; Symmonds' modification (socalled open Marshall-Marchetti-Krantz): narrowing of the bladder neck region by vesicotomy. marsupialization (Lat. marsupium pouch): surgical exposure of a cyst by opening, emptying, draining, and fixation of cyst vault to the adjacent skin. Occasionally used for the treatment of Bartholin's (pseudo) cyst; after incision of the cyst, the cut edges of the remaining cyst wall are sutured to the mucosa of the vestibulum vaginae. Similarly, the marsupialization of cysts within organs (e.g. pancreatic

mastitis, parenchymatous cysts) with fistula formation to the gastrointestinal tract. maseulinization: virilization*, masochism (Leopold von Sacher-Masoch, author, 1835-1895): deviant sexual* behavior, achieving sexual excitation and satisfaction only from psychological humiliation and submission or physical maltreatment and punishment Highly specialized forms of sexual rites can develop against the background of sadomasochistic relationships. The combination of pain and lust in men and women occurs regularly as part of common sexual experiences. Opposite: sadism*; cf. sadomasochism, mastalgia: syn. mastodynia*. mastectomy (Gr. ektemnein to cut out): ablatio mammae, breast amputation; the operative removal of the female breast; 1. simple mastectomy: removal of the mamma with retromammary fat tissue and fascia of the greater pectoral muscle without lymphadenectomy; 2. modified radical mastectomy: routine technique for the operative treatment of carcinoma of the breast (Patey*s modification of the Halsted's operation) with removal of regional, intrapectoral, intraclavicular, and axillary lymph nodes and retention of both pectoral muscles. Advantages: shortened surgical procedure, improved cosmetic results, decreased incidence of lymphedema of the arm, improved mobility of upper arm and shoulder, more favorable condition for later breast reconstruction (see mammoplasty). 3. radical

Mastectomy: Bilateral capsular fibrosis after subcutaneous mastectomy

mastectomy: see Halsted's operation. Cf. mastectomy, subradical. mastectomy, subcutaneous: subradical mastectomy* for the treatment of breast* carcinoma with complete removal of the glandular body (skin, nipples, areola mammae are maintained). Prerequisite is an isolated tumor with a maximum diameter of 2 cm, concurrent axillary lymphadenectomy and possibly radiation. Breast reconstruction usually is performed simultaneously (usually by placement of a skin expander; see mammoplasty). mastectomy, subradical: surgical treatment of small breast carcinomas while preserving the breast or facilitating later reconstruction (see mammoplasty). Procedures:

1. tumor excision, so-called tylectomy*; 2. segmentectomy; 3. quadrant* resection; 4. removal of the complete glandular tissue and replacement by a breast* prosthesis; see mastectomy, subcutaneous. mastitis: inflammation of the female breast gland (mastadenitis); signs and symptoms:

i

Mastitis: Advanced case of mastitis with abscess formation

pain, fever, reddening infiltration, later possi bly fluctuation as an indication of tissue liquefaction. Cf. mastopathy. After nursing, the maternal mamilla is colonized with staphylococci in approx. 90% of cases. mastitis, chronic: usually occurring in older women; mastitis* without fever, associated with minimal tenderness and firm tissue consistency of the breast; histological tissue diagnosis is necessary to exclude breast carcinoma. mastitis, granulomatous: non-specific mastitis*, independent disease; destructive granulomatous process. mastitis, interstitial: phlegmonous inflammation with diffuse lymphatic or hematogenous spread in the connective tissue of the female breast, with subsequent tissue liquefaction; type of mastitis* occurring after invasion by bacteria (usually Staphylococcus aureus), usually through mamillary lesions. Tissue liquefaction directly below the mamilla may result in a subareolar abscess, while at the level of the pectoralis fascia sub- or retromammary abscesses* occur (frequently communicating). mastitis neonatorum: mastitis of the fetal breast gland due to stimulation from placental hormones (occasionally with abscess formation), usually occurring between the 4th and 6th day postpartum in both sexes. Can be caused by secretion of so-called witch's*-milk. mastitis, parenchymatous: intracanalicular inflammation of the female breast gland; mastitis* after colonization of the milk ducts (usually Staphylococcus aureus), especially if milk flow is obstructed, also in the presence of tissue defects or inflammation of the mamilla. 151

mastitis, puerperal

mastitis, puerperal: mastitis of the nursing puerpera, usually occurring 2-4 weeks after delivery; most common form of mastitis, usually interstitial; see mastitis, interstitial. Organism: Staphylococcus aureus in over 90% of cases. Transmission occurs usually from the child to the mother by nursing*. mastodynia (Gr. odyne pain): usually a premenstrual sensation of tension and breast enlargement, frequently associated with vague or localized tenderness (mastalgia); clinical symptomatology with multiple etiologies, e.g. endocrine-vascular edema, mastopathy, occasionally breast carcinoma, frequently unclear etiology. This term was used previously for the most frequent type (mildest type) of mastopathy (out-dated classification). mastopathy: degenerative or proliferative changes in the breast, frequently occurring during sexual maturity, mainly between 35

Mastopathy: Fibrocystic mastopathy of the f e m a l e breast with induration and cystic degeneration of the tissue in this section

and 50 years of age. Signs and symptoms: nodular indurations, tenderness (mastodynia*), occasionally pathological secretions (secreting* nipple, bloody discharge of the breast*); premenstrual deterioration of symptoms is characteristic. Etiology: possibly hormonal imbalance between estrogens and progesterone. Differentiation according to diagnostic and prognostic aspects (Prechtel): 1. simple mastopathy (I) with increase in connective tissue, distortion of the lobar system, and dilatation of the milk ducts with formation of cysts (mastopathia cystica fibrosa); proliferation of the intraductal epithelium does not occur. Most prominent form of cystic mastopathy is Reclus' disease (mastopathia fibrosa chronica cystica). Solitary cysts may be seen with pneumocystography. 2. mildly proliferating mastopathy (II) with intraductal solid adenoid or papillary proliferations of the lactiferous ducts; special form: sclerosing adenosis (Schimmelbusch) with lobar proliferation and hyperplasia of the acinar epithelium of the glands and small ducts, with occasional nodular confluence (so-called tumor adenosis), benign; differential diagnosis: separation from scirrhous breast* carcinoma occasionally difficult. 152

3. atypical proliferative matopathy (III) with intraductal, intra-acinous, and intrapapillary proliferation of the epithelium, cellular and nuclear atypia, and increased mitosis; differential diagnostic separation from preinvasive malignancies of the lactiferous ducts is frequently difficult, only possible by histology (biopsy*!). Relationship between mastopathy and breast carcinoma: simple mastopathy is not considered as precancerous. Mastopathy II and III are at increased risk of change to malignancy; regular examinations necessary; occasionally indication for (bilateral) subcutaneous mastectomy*. mastoptosis (Gr. ptosis fall): syn. mamma pendulans, sagging breast; hypertrophic, adipose type frequently seen in multipara, especially in the climacteric due to increasing obesity, or atrophic type mainly seen in older women with connective tissue deficiency. Symptoms: occasionally vague breast tenderness. Therapy: preferably conservative treatment with supportive brassiere, in young women mammoplasty* may be necessary. masturbation: onanism, in both sexes; early and frequently orgasmic (usually manual) self-stimulation of the genital area, associated with (occasionally sexually and psychologically revealing) masturbation fantasies. Occurrence: in 75% of women and 90% of men. Average in unmarried young women, approximately once a week, in men twice a week. As mutual masturbation it is a form of sexual intercourse. maternal mortality: n u m b e r of m a t e r n a l

deaths from complications of pregnancy, delivery, and puerperium; usually calculated per 100,000 live births; in the F.R.G. in 1985 10.7 (1956:139.2; 1966: 65.1; 1976:36.3; 1980:20.6). Cf. anesthetic risk. maternity: expression for pregnancy* and the postpartum state; cf. prenatal care. maturation (Lat. maturatio maturity): process of completion of physical and psychological differentiation and integration of the demands of daily life. Physical maturation is reached in central Europe by women on average at age 16 and by men at age 20. The attainment of psychological and social maturation on the other hand has no temporal limitation, since it usually requires more prolonged individual development. maturation,

follicular:

development

of

some of the prenatally developed primary follicles in the ovary as part of the menstrual* cycle. Primary follicles (diameter approximately 45 μπι) consist of primary oocytes (see oogenesis), surrounded by a layer of epithelial cells (see ovarium, Fig.). In every menstrual cycle several primary follicles develop to secondary follicles; the oocyte increases in size, surrounding epithelium changes into columnar epithelium, becomes multi-layered and then forms a glycoprotein membrane around the oocyte (zona pellucida, oolemma*). Within the follicle cells a fluid-filled space develops (follicular cavity), with a mature tertiary follicle (Graaf s follicle, diameter 6 mm) containing an

measurements, pelvic

eccentrically located oocyte surrounded by cells (cumulus oophorus) of the follicle epithelium (granulosa cells). These cells are surrounded by two connective tissue layers, an inner layer (theca internal), and an outer layer (theca externa) which merges into the ovarian stroma. In the days before ovulation* the tertiary follicle grows to a diameter of approximately 15 mm. After ovulation the remnants of the follicular epithelium form the corpus* luteum. In each menstrual cycle usually only one follicle reaches the tertiary stage, while the remaining secondary follicles collapse and form so-called atretic follicles; cf. menstrual cycle (Fig.). maturation phase, follicular: f i r s t p h a s e

(usually from day 1 to day 14) of the biphasic menstrual* cycle, includes maturation of one or more follicles in the ovary and concurrently proliferation of the endometrium due' to the increase in estrogen production; the basal body temperature is usually below 36.9 CC. The follicular maturation phase is followed by the luteal phase; cf. maturation, follicular. maturity signs, neonatal: l e n g t h of t h e

body at least 48 cm, weight at least 2500 g, shoulder circumference larger than head circumference (Frank's sign), relative height of head 25 cm (Stratz), relative breast circumference 33-35 cm (Jaschke), well-developed subcutaneous adipose tissue, good skin turgor, pink color, scalp hair at least 2 cm, lanugo present only on shoulders, upper arms, and upper back, nails cover or reach beyond the tips of the fingers, labia majora cover the minora, testicle in the scrotum, firm cartilage of nose and ear. For the determination of gestational age several scoring systems are available, e.g. Petrussa* score, FarrMndex. Parallel to the above mentioned morphological signs of maturity, the gestational age" can be estimated from neurological development (see reflexes, primitive). Cf. Haase's rule, postmaturity signs, ossification centers.

est distance between the iliac crests): 28-29 cm; 3. distantia trochanterica (distance between the greater trochanters): approximately 31 cm; 4. conjugata externa: Baudelocque's diameter (upper edge of the symphysis to the spine of the last lumbar vertebra): 18-21 cm on average. The external measurements are measurements of the false pelvis; however, they provide information on the relationship of the dimensions of the obstetrically important true pelvis. Platypelloid pelvis must be suspected when the difference between distantia cristarum and distantia spinarum is less than 1.5 cm.

maturity tests, intrauterine: m e t h o d s f o r

the determination of the maturity of the unborn child; currently mainly prenatal lung* maturity tests, in addition to determination of the fetal size* by intrauterine ultrasound* diagnosis; cf. cephalometry, intrauterine. Mauriceau-Veit-Smellie maneuver ( G u s -

tav von Veit, gynecologist, Rostock, Bonn, 1824-1903; William Smellie, gynecologist, London, 1697-1763; F r a n c i s Mauriceau, obstetrician, France, 1637-1709): obstetrical maneuver for the delivery of the after-coming head in breech* presentation; one hand reaches over the fetal shoulder (Caveat: brachial plexus* palsy). The index finger of the other hand is placed into the fetal mouth, while the fetal abdomen rests on the lower arm (see Fig.). Cf. breech maneuvers, assisted. Mayer-Rokitansky-Küster-Hauser

syn-

measurements, pelvic: I. e x t e r a a l

mea-

drome: see Rokitansky-Küster-Hauser syndrome.

surements: 1. distantia spinarum (distance between the two anterior/superior iliac spines): 25-26 cm; 2. distantia cristarum (long-

Pelvic measurements: Determination of conjugata externa (a); b: upper edge of the symphysis pubis

II. internal measurements (see Fig.): 1. conjugata anatomica (Promontorium to upper edge of symphysis). 2. conjugata anatomica vera obstetrica (median diameter): shortest distance between Promontorium and symphysis: 11 cm; 3. conjugata diagonalis: diameter from the lower edge of the symphysis to the Promontorium: approximately 13 cm; 4. diameter 153

meconium cle*, breast- and corpus carcinoma; cf. gestagens. Meigs' syndrome (Joe Meigs, gynecologist, Boston, 1892-1966): the presence of ascites* and (usually right sided) pleural effusion in association with benign ovarian tumors* (ovarian fibroma*), usually in older women. Rapid resolution of fluid accumulation after tumor resection. Unknown pathogenesis. The pseudo-Meigs' syndrome is associated with the same signs, however with malignant tumors (carcinoma of the ovary). meiosis (Gr. meiosis reduce, to make smaller): syn. reduction division; a basic genetic process, common to all sexual reproduc-

Pelvic measurements: a: distantia trochanterica 31 cm; b: distantia spinarum 25 cm; c: distantia cristarum 28 cm; d: transverse diameter 13.5 cm; e:interspinous diameter 10.5 cm; f: conjugate vera obstetrica 11 cm; g: oblique diameter 12.5 cm

obliqua between the sacroiliac joint and the iliopubic eminence of t h e opposite side (first oblique diameter from right posterior to left anterior, second oblique diameter from left posterior to right anterior): 12.5 cm. 5. transverse diameter: longest distance between the two lineae terminales (see pelvis): 13.5 cm. The conjugate vera obstetrica is 1.5-2.5 cm shorter than the conjugate diagonalis. meconium (Gr. poppy juice): fetal feces, black-green, due to the large biliverdin contents, usually passed postpartum; presence of meconium in amniotic fluid is considered a sign of intrauterine (temporary) distress; cf. amnioscopy; birth, high risk. meconium ileus: mechanical ileus of the newborn; occlusion of the large bowel by highly viscous meconium; frequently present in cystic fibrosis. May result in meconium peritonitis. meconium test: rapid test for the early recognition of cystic fibrosis by demonstration of elevated albumin contents in meconium. Screening test in newborns. medroxyprogesterone acetate: abbr. MPA; 6a-methyl-17-hydroxy-4-pregnene-3,20dione-17-acetate; C24H3404; androgenic gestagen, was originally used for the maintenance of high-risk pregnancies, but showed androgenic side effects (virilization of female fetuses). Therapeutic use: for oral hormonal contraception , in hirsutism*, anovulatory cy154

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Meiosis: 1: crossing-over; 2: normal meiosis; 3: nondisjunction tion, without which the number of chromosomes of a species would be perpetually doubled. The cells of higher organisms have a diploid chromosomal set, a combination of paternal and maternal hereditary substances. Spermatogonia/oogonia do not in this respect differ from other body cells. Through meiosis, the gametes (sex cells) get a haploid set; by fertilization two gametes again fuse to a diploid cell, the zygote, out of which a new individual originates. Meiosis is a complex process which is begun by chromosome pairing: each chromosome joins with its homologous chromosome stemming from the other parent. Through breakage and recombination, an exchange can occur between equally long segments of homologous chromosomes, the so-called crossing-over phenomenon. Subsequently through formation of spindles a second separation of the paired bivalent chromosomes follows, resulting in four respective homologous cells. Non*-disjunction of homologous chromosomes produces a gamete with too many or too few chromosomes. Fertilization results in organisms which frequently prove to have major

menstrual cycle defects (e.g. Klinefelter's* syndrome, Down's* syndrome). Cf. aberrations, chromosomal; mitosis. membrana obturatoria (Lat.): partially closes the foramen obturatum of the hip bone; a craniomedial gap is completed by a groove in the inferior plane of the upper branch of the os pubis (sulcus obturatorius) to canalis* obturatorius. membranes, fetal: secondary birth membranes which are attached to the edge of the placenta* composed of three layers; two fetal:

(in Eskimos approximately 22 years, southern Europe approximately 10-12 years). menarche, delayed: delayed onset of menstruation*; cf. puberty, delayed. menarche, premature: early onset of menstruation (menstruation* before age 10). menopausal symptoms (Gr. pauein terminate): also autonomic-climacteric syndrome; with the typical triad of hot flushes, dizziness, sweating; can occur premenopausal^, especially in younger women after operative castration*. In addition to these common autonomic disturbances, the syndrome includes psychological (irritability, apathy, decline in performance, sleep disturbance, etc.), and somatic (atrophy of the genital organs and breasts, obesity, osteoporosis) symptoms. menopause: the menopause is defined as the last menstruation* with no f u r t h e r ovarycontrolled uterine bleeding for one year: usually between 45-50 years of age. Early m e n a r c h e is frequently associated with late menopause and vice versa; a delay of menopause into older age has been observed in the last decade; see also climacteric. Cf. sexual maturity. menopause, delayed: considerably delayed climacteric* with onset beyond 50 years of age. menopause, premature: early climacteric due to premature ovarian failure before 42 years of age. monorrhagia: prolonged menstrual bleeding; cf. menstrual cycle. menses (Lat. months): the monthly m e n struation*. menses, adolescent: see adolescent menses. menstrual cycle: time from the first day of menstruation* to the last day before the next period, including associated changes; duration of the menstrual cycle is on the average 29.5 days, with large variation, a n d however, some individual constancy. Classification: 1. m e n struation (day 1-4); 2. post-menstruum (day 5-12); 3. intermenstruum (day 12-17); 4. pre-

Fetal membranes: 1: amnion; 2: chorion and decidua capsulars; 3: stratum compactum of the decidua vera; 4: stratum spongiosum of the decidua vera; 5: muscularis uteri amnion* (sheepskin) and chorion* (villous skin), and a maternal: decidua* (sieve skin); see Fig. menarche (Gr. men, menos month; arche beginning): time of the first menstruation* in puberty; in central Europe the menarche starts between 13 and 13.75 years (due to acceleration* approximately 1-2 years earlier t h a n in the 19th century). The onset is dependent on ethnic, climatic, and constitutional factors

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1 2 3 4 Menstrual cycle:, Follicle development in the ovary throughout a cycle; 1: primary follicle; 2: secondary follicle; 3: tertiary follicle;4: mature Graaf'sfollicle; a: oocyte; b:zona pellucida;c: granulosa cells; d: basal membrane; e: theca cells 155

menstrual cycle

Menstrual cycle: Normal values for LH, FSH, estradiol, and progesterone in the serum throughout an ovulatory cycle (radioimmunological assay; mean and standard deviation); x: days of cycle; y,: LH (ng/ml); y2: FSH (ng/ml); y3: estradiol (pg/ml); y4: progesterone (ng/ml); a: LH peak menstruum (day 17-28). The characteristic cyclical changes which can be recognized in the whole organism, in the genital tract, and especially in the endometrium are determined in the usual biphasic cycle by the ovarian hormones, which themselves are dependent on the hypothalamic'-hypophyseal axis. In the first part of the cycle FSH* stimulates estrogen production in the mature follicle (follicular maturation phase) of the ovary which itself stimulates proliferation of the endometrium. Ovulation occurs after a sharp rise of FSH and 156

LH approximately on the 12th day, but can, however, occur considerably earlier or later; the length of the cycle (see above) is determined mainly by the length of the proliferative phase; transformation of the endometrium into the pregravid secretory phase is due to progesterone (corpus luteum phase or luteal phase) which is produced by the corpus* luteum under LH and later LTH* influence; duration of the secretory phase is fixed at 14 days. In the absence of fertilization and nidation, the production of ovarian hormones from

metastasis

follicle a

b

mesenteric plexus: see plexus mesentericus inferior. mesoderm: (embryol.) middle of the three embryonic germ* layers which begins to differentiate at the stage of the embryonic* disc (c. 17th day) and then develops into the skeleton, connective tissue muscles, urogenitalia, spleen, blood vessels, heart, blood cells, and other structures.

corpusjuteum c

d

e

f

mesonephric duct: see ductus mesoneph-

A B

C D

Menstrual cycle: Changes of endometrium and ovary: a: developing; b: ready to burst; c: ruptured; d: proliferation and vascularization; e: full development; f: regression; A : desquamation; B: proliferation; C: secretion; D: desquamation

the degenerating corpus luteum decreases, the prerequisite for maintenance of the endometrium disappears, and shedding of the endometrium occurs (desquamation phase: menstruation). Further cyclical changes: see body temperature, basal; colpocytology; mucus, cervical. Cf. premenstrual syndrome; menstruation disorders; cycle, anovulatory; preovulatory phase. menstrual

regulation:

termination

of

pregnancy* within two weeks of a missed period; a small plastic tube is inserted through the cervical canal and the decidua, and the implanted embryo is removed by suction with an electric vacuum pump or special syringe. Advantage: considerably less complications than with termination 4-6 weeks later. Disadvantage: the procedure is performed unnecessarily if pregnancy has not been confirmed. Cf. curettage, suction. menstruation (Lat menstruum monthly flow): also menses, monthly bleeding, period; with bleeding associated shedding of the endometrium throughout the reproductive period; visible reflection of the complicated functions of the inner sexual organs throughout the menstrual* cycle. True menstruation is only present if during the previous cycle a corpus* luteum was formed, indicating ovulation*. Cf. eumenorrhea; menarche; menopause; cycle, ovarian. menstruation

disorders:

anomalies

of

menstruation*; types: 1. anomalies of the bleeding rhythm: oligomenorrhea*, polymenorrhea*, usually hormonal cause; 2. anomalies of the amount of bleeding: hypomenorrhea*, hypermenorrhea*; usually organic cause; 3. anomalies of duration: menorrhagia*, brachymenorrhea*; 4. intermenstrual bleeding* in biphasic cycle: premenstrual bleeding*, postmenstrual bleeding*, mid-cycle bleeding* (special type: ovulatory bleeding*); cause may be hormonal or organic; 5. persistent follicles* (special form of dysfunctional bleeding*); 6. amenorrhea*. mentoanterior: see face presentation, mentoposterior: see face presentation.

ricus. mesonephros: primordial kidneys in the embryonal period* which disappear close to the end of the second month, and then are replaced by the metanephros; the male epi- and paradidymis and the female ep- and paroophoron are derived from its rudiments. mesosalpinx: peritoneal duplication; mesentery of the fallopian tube; see ligamentum latum uteri. mesoverium: mesentery of ovary; peritoneal duplication; see ligamentum latum uteri. mesterolone (INN-Ε): mesterolonum (INN-L), la-methyl-17ß-hydroxy-5a-androstane-3-one (IUPAC); CAS-No. 1424-00-6; C20H32O2; molecular weight 304.46; orally active androgen which has no influence on gonadotropin excretion: Use: for androgen substitution in hypogonadism, oligozoospermia; cf. androgens. mestranol (INN-Ε): mestranolum (INN-L), ethinylestradiol-3-methylether (IUPAC); CAS-No. 72-33-3; C^H^Oj; molecular weight

,

OH Jo—C = CH

jfjLJ

CHjO Mestranol

310.42; 3-methylether of ethinylestradiol*. Use: synthetic estrogen which is particularly suitable for oral use, especially in combination with a gestagen for hormonal contraception*; cf. estrogens. metastasis (Gr. metastasis change, migration): (gen.) a secondary focus which occurs as a consequence of the spread of material from a localized (primary) disease process to other locations within the organism; in the narrow sense tumor metastasis, specifically of malignant tumors (carcinoma, sarcoma, etc.) by spread of tumor cells; differentiation according to route of spread: local (in the vicinity of the primary tumor), regional (lymphatic involvement of the closest lymph node group), and distant metastasis; by the type of spread: hematogenous (spread via the blood vessels after invasion of the vascular system), lymphatic (spread of the tumor cells through the lymphatic system and infiltration of the regional lymph nodes by malignant tissue), implantation metastases (implantation of tumor cells 157

methods, invasive in serous membranes, mainly pleura and peritoneum), contact cancer (metastasis caused by contact with an adjacent tumor), and inoculation metastasis (for example in puncture channels and wounds after surgery). methods, invasive: term for diagnostic and therapeutic procedures which involve entry of medical equipment (in the wider sense also ionizing radiation) into the body, and which therefore are associated with a risk to the health of the patient (e.g. cardiac catheterization). An example of a non-invasive method is the conventional ECG. methylergometrine (INN-Ε): methylergometrinum (INN-L), N-(l-hydroxymethylpropyl)-lysergamide (IUPAC); CAS-No. 113-42-8; C20H25N3O2; molecular weight 339.44; ergot alkaloid with direct stimulatory action upon the smooth muscles of the uterus but with no vascular action. Therapeutic use: esp. (obst.) to arrest postpartum hemorrhage*; cf. ergotamines. metritis (Gr. metra uterus): syn. myometritis*. metropathia haemorrhagica: obsolete term for persistent bleeding due to a cysticglandular hyperplasia*; cf. follicle, persistent. metroplasty: reconstructive uterine surgery to correct congenital or acquired uterine malformations* (for example Strassmann*-Jones operation in uterus septus, subseptus, or arcuatus) or in patients with uterus myomatosus and desire for future pregnancy (see myoma). metrorrhagia: uterine bleeding separate from menstruation*, lasting beyond 7 days. Cause: 1. hormonal (acyclical dysfunctional bleeding*): e.g. due to disturbances in follicle »

flow

1.

heavy normal light

1 I

2

3.

1 L

4.

5.

Principle: all not obviously benign areas with microcalcifications require directed biopsy, since in some cases mammography cannot rule out a malignancy. microcephaly: abnormally small circumference and contents of the skull compared to the appropriately grown remainder of the body; so-called birdhead or aztec type. Microcephaly is frequently associated with various abnormalities of skull shape (dyscrania).

cycle 6.

[ 1111111

il Metrorrhagia (menstrual calendar)

maturation resulting in breakthrough bleeding*. The failure of hormonal therapy indicates an organic cause. 2. organic (carcinoma, endometritis, submucosal myoma, polyp, etc.): curettage is necessary in post- and premenopause, if the bleeding continues for more than three weeks, or if in the absence of organic causes hormone treatment is unable to control metrorrhagia within 2-3 days (see also climacteric). In adolescent* menses, curettage is avoided if at all possible (exclusion of hemorrhagic diathesis as part of a medical disorder after failure of hormone therapy). Recurrence is frequent (recognizable by the monophasic basal body temperature curve). Michaelis' rhomboid (Gustav Michaelis, gynecologist, Kiel, 1798-1848): a rhomboidshaped area between the processus spinosus 158

of the last lumbal vertebra, the spinae iliacae dorsales craniales (iliacae post, sup.), and the connecting point of the buttocks, important in the assessment of pelvic deformities (asymmetry, flattening); a normally formed pelvis has a squared rhomboid. Any deviation of this form indicates a narrow pelvis*. microcalcifications: (gyn.) calcium deposition in the breasts confirmed by mammography*, considered characteristic of malignancy, if the appearance is crystalline, if they are fine-grained and in a cluster or segmental location radially towards the nipple, or diffusely penetrate the whole breast parenchyma.

Micro-invasive carcinoma: Histological preparation of the cervix with web-like infiltration of the stroma Classification according to etiology: 1. primary microcephaly without recognizable etiology is called familial or uncomplicated microcephaly, can also be associated with various dysostoses; 2. secondary microcephaly due to prenatal diseases* (rubella* embryopathy, toxoplasmosis*) which frequently can also lead to hydrocephalus* (hydromicrocephaly). micro-invasive carcinoma: true invasive carcinoma* of limited extension, can only be diagnosed histologically. Cf. carcinoma in situ. micropill: commonly used term for low-hormone monophasic pills with a daily dose of less than 50 μg estrogen for hormonal contraception*. mid forceps: see forceps extraction, mifepristone: 17 ß-hydroxy-11 ß-(4-dimethylaminophenyl)-17a-(l-propynyl)estra-4,9-diene-3-one; C29H3e02N; also RU 486; antigestagen with a 5-times greater affinity for progesterone receptors than progesterone* and a 3-times

mole greater affinity for glucocorticoid receptors t h a n dexamethasone. To date mifepristone has been used experimentally for t h e induction of menstruation, for the termination of pregnancy, and the induction of birth; in the future its high affinity for progesterone receptors might play a part in the treatment of receptorpositive breast carcinomas. migration of ovum: also ovum transport; transport of the fertilized ovum (or zygote) in the tube (due to tubal motility, secretions, and ciliary action, controlled by ovarian hormones) toward the uterine cavity; duration is approximately 3-4 days; throughout this time, the zygote passes through several divisions (see cleavage). Nidation* of blastocyst* approximately 6 days after ovulation. Risk of ectopic pregnancy* if the tube is not patent. milk: see breast milk, cow's milk, colostrum, milk ducts: ductus* lactiferi. milk duct carcinoma: see comedocarcinoma. milk duct papilloma: isolated or multiple papillomatous proliferation in the milk ducts below the mamilla, usually in cystically dilated areas; occurs mainly in women at the time of menopause and can present as bloody discharge of the breast* (papilloma tear). The usually benign milk duct papilloma can change into a malignant tumor. milk fistula: discharge of breast milk through a fistula which is connected with a milk duct; can occur in puerperal mastitis* due to tissue necrosis, usually with spontaneous recovery after discontinuation of nursing. milk line: residue of a striate thickening of the epidermis which appears in the 2 month old embryo on both sides of the body; the larger part of the milk line disappears, a smaller part remains in the mid-thoracical re-

Milk line: The points designate possible occurrences of accessory breasts.

gion and becomes the m a m m a r y gland. Accessory nipples (polythelia) or complete breasts (polymastia) may be found at any position along the milk line. milk pores: see nipple, ductus lactiferi. milk retention: galactostasis; retention of

breast* milk in the glandular and ductal areas of the breast of a puerpera, secondary to obstruction or inadequate emptying, with risk of development of parenchymatous mastitis* and cyst formation; previously frequent cause of puerperal fever. milk secretion, neonatal: so-called witch's* milk. milk, trensitional: so-called transitional breast* milk. Milroy's disease (William F. Milroy, physician, Omaha, 1855-1942): see trophedema. minipill: commonly used t e r m for hormone preparations containing exclusively gestagens* (norethisterone*, levonorgestrel*, or lynestrelnol*), which are used for hormonal contraception* without the inhibition of ovulation. miscarriage: see abortion, missed abortion: see abortion, missed, missed labor: the retention of a dead fetus beyond normal gestation (see intrauterine fetal death) due to t h e lack of contractions; see also dead fetus syndrome. mitosis (Gr. mitos thread): mitotic division, indirect nuclear division, equatorial division; identical reduplication of genetic material and distribution of a complete set of chromosomes to each daughter cell. Mitosis includes thereby three processes normally closely associated with each other: 1, the identical DNA-reduplication which is visible as longitudinal separation and doubling of chromosomes. 2. the karyokinesis, the orderly distribution of

daughter chromosomes to the new daughter nuclei. 3. the cytokinesis, the association of areas of cytoplasm to each nucleus through cell division or cleavage. Usually mitosis is divided into four phases: prophase, metaphase, anaphase, and telophase. Prophase: the already longitudinally separated chromosomes* become visible, the nuclear envelope disintegrates. Metaphase: the chromosomes arrange in an equatorial plane. Anaphase: the separate halves of the chromosomes are pulled apart by the spindle microtubules. Telophase: the chromosomes are again longitudinally separated and encircled by a nuclear membrane, both daughter cells go into the interphase (work phase). mittelschmerz (Ger. mid-pain): pain in the lower abdomen, approximately halfway between menstruations, due to peritoneal irritation after rupture of the follicle (see ovulation). mole (Lat. mola deformed embryo): abnormal product of conception which, depending on its consistency, is classified into hydatidiform mole*, blood mole*, embryonal (or true) 159

mole, blood mole*, and Breus'* mole; cf. ovum, blighted. mole, blood: type of blighted ovum* where after death of the embryo peri- and intra-ovular bleeding occurs without the pregnancy being expelled; a completely hemorrhagic product of conception is called blood mole, and by organization and leaking out of the hemoglobin the lighter colored carneous mole develops. Calcium deposition can convert these into calcified moles. mole, calcified: syn. stone mole; see mole, blood. mole, carneous: syn. fleshy mole; see mole, blood. mole, embryonal: blighted ovum* with a dead and usually abnormal fetus up to 22 cm in length. mole, fleshy: see mole, blood, mole, hydatidiform: syn. cystic mole, mola hydatiformis, also grape mole; partial or complete hydropic-edematous degeneration of the chorionic villi of the placenta* with grapesized and grape-like vesicles (Fig.) filled with

^fSr b

^ ^

Hydatidiform mole: a: normal villous tree; b: abnormal villous tree in a hydatidiform mole

clear fluid; at the same time, there is proliferation of cyto- and syncytiotrophoblast of varying degrees (type of trophoblast* tumor). The continuing invasive nature of the trophoblast*, which is usually only present at a limited phase in implantation*, can result in an invasive mole (chorioadenoma* destruens). Etiology: probably abnormal embryonic development; the abnormal trophoblast persists while the embryoblast* degenerates. The disturbance in development begins usually one month after conception*. Signs: uterus larger than expected (fundus* height), absent fetal heart* tones and movements*, occasional vaginal bleeding with passage of vesicles, increased serum levels of HCG*, which may be associated with luteal cysts* of the ovaries or pre*-eclampsia. Therapy: medical treatment with uterotonics*, curettage (Caveat: uterine perforation, heavy bleeding!). In view of the possibility of change into a malignant chorioepithelioma* from remnants of a hydatidiform mole, the patients require serial longterm follow-up. molimina (Lat. exhausting efforts): generalized term for pain, discomfort; (gyn.) mo160

limina menstrualia: complaints in connection with menstruation* in the presence of cryptomenorrhea*; special form: molimina menstruationis sine menstruatione: menstrual symptoms in women after hysterectomy (psychological origin?). monilial vulvovaginitis: see Candida vulvovaginitis. moniliasis, vaginal: see Candida vulvovaginitis. monitoring, intrapartum: see cardiotocography. monochorionic: having only one common chorion*; e.g. twins* with one chorion. monosomy: the absence of the second chromosome in an otherwise diploid set of chromosomes (genome mutation), for example due to non*-disjunction or chromosome loss; in h u m a n s only monosomy 45, X0 (Turner's* syndrome) is known. Loss of a fragment of a chromosome (deletion) is called partial monosomy (e.g. cri-du-chat syndrome). mons pubis: mons veneris, mountain of Venus; fat pads of the anterior vulvar region with the characteristic pubic hair triangle of the woman; part of the pudendum* femininum; see genital organs. monster: abnormality, anomaly; abnormality with absence of parts of the body (monster per defectum), with localized anomalies (monster per fabricam alienam), with excessive supernumerary anomalies (monster per excessum), duplications (monster duplex). Montevideo unit: measuring unit for the evaluation of the strength of uterine contractions; defined as product of contraction, amplitude, and frequency over 10 minutes; cf. tocography, contractions. Montgomery's glands (William Montgomery, gynecologist, Dublin, 1797-1859): glandulae areolares (mammae); see areola mammae. morcellation: dissection, e.g. of large myomata of the uterus in vaginal hysterectomy. morning-after pill: commonly used term for postcoital contraception*. morning sickness: see hyperemesis gravidarum. mortality, infant: see infant mortality, mortality, intrauterine: see abortion, stillbirth. mortality, maternal: see maternal mortality. mortality, neonatal: see infant mortality, mortality, perinatal: see infant mortality, morula (dim. of Lat. morum mulberry): solid globular collection of blastomeres*; the result of the cleavage* on the 3rd-4th day after fertilization. Develops into the blastocyst*. mosaic pattern: (gyn.) suspicious colposc o p y finding: iodine-negative, irregular mosaic-like small white-yellow areas (hyperkeratoses), which are separated by red lines (capillaries). Cf. colposcopy, leukoplakia. mother, surrogate: see surrogate mother, movements, fetal: fetal movements in utero; noticed by primiparae approximately at 19 weeks, by multiparae between 15-19 weeks. Confirmation: palpation.

multipara

MRA: abbr. for medroxyprogesterone* acetate. mucosal prolapse, urethral: prolapse of

the urethral mucosa from the meatus, usually in the senium; often the cause of nonspecific genital bleeding in older women (superficial excoriation due to underwear or pads); ablation by cautery. mucous membrane, vaginal: tunica mu-

cosa vaginae; so-called vaginal mucous membrane, although it possesses no mucoid glands; consists of multi-layered, non-cornified glycogen-rich squamous epithelium and a lamina propria rich in elastic fibres and veins with wide lumens. mucus, cervical: slightly alkaline secretion of the endocervical glands; consistency and amount dependent on the physiological hormone changes in the menstrual* cycle (see Fig.); contains among others the glycoprotein mucin, aminoacids, sugar, enzymes, and electrolytes; water content up to 90%. The mucus, which is only at the time of menstruation* and ovulation* not highly viscous, is a useful protection against ascent of bacteria and sperm into the uterus. Estrogen dominance results in decreased viscosity and the ability to form a string (spinnbar). The spinnbarkeit is largest just before ovulation (at least 6-8 cm) and indicates peak estrogen activity, the woman is now in the pre-ovulatory phase where the mucus is maximally permeable by the sperm (see spinnbarkeit test); the ferning test (see fern-

ing) is positive. The progesterone influence in the secretory phase is associated with decreased formation of viscous secretion; ferning is absent, sperm penetration is decreased or absent. Functional diagnosis: see cervix score. Cf. fertile days. mucus plug: closure of the cervical canal by cervical mucus*. Müller's maneuver (Arthur Müller, gynecologist, Munich, 1863-1926): delivery of

shoulder and arms in breech* presentation; development of the anterior shoulder through strong downward pull, the posterior shoulder through strong upward pull; must be followed by Mauriceau*-Veit-Smellie maneuver; cf. breech maneuvers, assisted. miillerian duct (Johannes Müller, physiologist, Berlin, 1801-1858): embryonal sexual duct; in the female sex it develops into tube, uterus, and superior vagina by caudal fusion with the opposite müllerian duct; in the male to the pedunculated hydatid (appendix testis) and into the utriculus prostaticus. Cf. müllerian duct cyst, müllerian mixed tumor. müllerian duct cyst: epithelial cyst, originating from remnants of the müllerian ducts, usually lined by single layered cubital, mucus-forming forming epithelium. Occurrence: anywhere within the female genital tract, usually in the uterus or the vagina (75% of all vaginal cysts), frequently localized on the posterior wall; may reach walnut size and in a pedunculated form protrude into the vagina. Clinically benign. miillerian

days

Cervical mucus: Schematic presentation of the cyclical changes

tumor,

mixed:

consisting

of

several epithelial and mesenchymal components from the pluripotent epithelium of the muellerian ducts. Occurrence: usually in the uterus, however, also seen in the ovary, tube, and rarely in the vagina. Benign tumors are extremely rare, far more often the mixed müllerian tumor is malignant (see sarcoma of uterus). multigravida (Lat. multus much): woman who has been pregnant at least six times; cf. history, obstetrical. multipara (Lat. parere give birth): woman 161

musculus bulbospongiosus

who has given birth several times, especially more than five children; cf. history, obstetrical. musculus

bulbospongiosus

(dim.

from

Lat. mus mouse): centrum tendineum perinei, median raphe at the lower surface of the bulbus and corpus spongiosum penis, sphincter ani ext. < — > lateral surface of the corpus cavernosum penis, fascia diaphragmatis urogenitalis inf., back side of penis (includes the bulbus vestibuli in women); innervation: n. pudendus; function: compression and shortening of the urethra, intermittent emptying by ejaculation. Cf. pelvic floor. musculus coccygeus: muscle of coccyx; spina ischiadica < — > lateral surface of os coccygis and os sacrum; at the inner surface of the lig. sacrospinale; innervation: n. pudendus; supports the pelvic diaphragm* in its dorsal aspect; see pelvic floor. musculus detrusor vesicae: m u s c u l a t u r e

of the wall of the bladder (tunica muscularis); forms a complex framework of bundles of smooth muscle fibres, in which a middle circular layer can only be poorly distinguished from an inner and outer longitudinal layer. Function: supports abdominal pressure during micturition. musculus ischiocavernosus: m u s c l e of os

ischium and corpus cavernosum; r. ossis ischii < > tunica albuginea corporis cavernosi penis (clitoridis). The paired muscles encircle the cavernous bodies attached to the lower branches of the os pubis as crura penis and/or clitoridis; innervation: nn. perinei; function: augments erection and in men ejaculation. musculus levator ani: muscles from both sides form a funnel-shaped sheet which helps to close off the pelvic outlet (diaphragma pelvis). The most anterior muscle bundles from both sides (levator thighs) leave a gap between them for passage of rectum (vagina), ureter: levator gateway (porta levatoria). Subdivisions: m.pubococcygeus:ospubis < — > centrum tendineum perinei, rectum, sphincter ani ext., os coccygis, os sacrum; m. pubovaginalis (m. levator prostatae): fibres of the latter extending to the vaginal wall (prostate fascia); m. puborectalis: os pubis < > looped around the flexura perinealis recti; m. ileococcygeus: arcus tendineus musculi levatoris ani < > lig. anococcygeum, os coccygis; innervation: plexus sacralis; function: holds and supports the pelvic viscera, strengthens the m. sphincter ani externus. See pelvic floor, fossa ischiorectalis. musculus sphincter ani externus: e x t e r n a l

striated muscle for closure of anus; pars subcutanea: subcutaneous connective tissue behind the anus < — > skin before the anus, fascia, and raphe of the m. bulbocavernosus; pars superficialis: os coccygeus, ligamentum anococcygeum < > centrum tendineum perinei; pars profunda: starting from centrum tendineum loop formed around the canalis analis of the rectum. Innervationen. perinei;function: closure of the canalis analis. Cf. pelvic floor. musculus sphincter urethrae:

musculus

sphincter

vesicae:

so-called

Lisso-sphincter; smooth muscle, involuntary contraction of the bladder sphincter at the bladder ostium (ostium urethrae internum). musculus transversus perinei profundus:

deep transverse perineal muscle, diaphragma urogenitale; trapezoid-shaped muscle sheet between both sides of the os ischium and the lower branches of the os pubis; innervation: nn. perinei; function: closure of the ventrocaudal area of the pelvic ostium, main component of the urogenital diaphragm; cf. pelvic floor, fossa ischiorectalis. musculus transversus perinei superficia-

lis: superficial transverse perineal muscle, variable; r. ossis ischii < — > centrum tendineum perinei along the background of the musculus* transversus perinei profundus; innervation: nn. perinei; see pelvic floor. mutagenesis (Lat. mutare to change; Gr. genesis production): process by which a mutation* is induced. mutagenicity: potential of an agent to induce a mutation*. mutagens: agents inducing mutations, e.g. ionizing radiation (alpha radiation stronger than beta radiation and gamma radiation), ultraviolet radiation (maximum around 260 nm, the maximum absorption for DNA), certain chemical substances, viruses. Medications can also have mutagenic effects (see Table). Corresponding mutagenic effects have been experimentally proven in microorganisms, cell cultures, or in animal studies, exogenously induced mutations also in humans. Somatic mutations are seen today as a possible cause of Mutagens Mutagenic pharmacological agents I.

Cytostatics Alkylating agents (e. g. chlorambucil, cyclophosphamide, busulphan, melphalan) Antimetabolites (e. g. fluorouracil, propylthiouracil, cytarabine, 6-mercaptopurine, folic acid antagonists) Antibiotics with cytostatic action (e. g. bleomycin, doxorubicin, daunorubicin, mitomycin, rufocromomycin/streptonigrin) Procarbazine

II. Alkaloids colchicine, vincristine, vinblastine III. Antibiotic, bacteriostatic, and antiparasitic agents (e. g. dactinomycin, griseofulvin, hycanthone, oxyquinoline, isoniazid, lucanthone, nitrofurantoin)

so-called

rhabdo-sphincter, striated; circular fibres of the musculus* transversus perinei profundus around the pars membranacea of the urethra; 162

innervation: nn. perinei; function: closure of the urethra. Cf. pelvic floor.

IV. Immunosuppressives (e. g. azathioprine)

myoma carcinogenesis. Hereditary changes due to exogenously induced mutations have as yet not been proven in humans; cf. mutation. mutant: individual in whose genome at least one gene has been altered as a result of mutation. mutation: inherited changes in genetic material which are not a result of recombination or segregation. Mutations without identified etiology are known as spontaneous mutations. Somatic mutations do not affect the primordial germ cells, i.e. they are not hereditary. Induced (exogenously produced) mutations are set off by mutagens*. One differentiates: 1. mutations of genome (changes in number of a chromosome set); 2. chromosomal aberrations* (structural changes in chromosomes, e.g. breakage); 3. gene mutations (changes in the base sequence of the DNA of a single gene): a) point mutations: exchange of a purine base for another purine- (transition) or pyrimidine base (transversion); b) deletion mutation: loss of more than one base through which a large amount of genetic information is lost; c) insertion mutation: changes in the base sequence by additional DNA; d) raster mutation: additional molecules of certain materials in the nucleotide chain which prove to have a similar size and structure to nuclear acid bases (e.g. acridine-dye); corresponding displacement of the nucleotide sequence results in the synthesis of a changed gene product (protein). If three molecules are incorporated one after another, the original triplet order is again restored. mutation, conditionally lethal: mutation* which causes such a change in a gene that the corresponding change in the gene product leads to lethal effects under certain growth conditions; cf. lethal factor. mutation, lethal: mutation* which is not compatible with life; see lethal factor. mutation rate: syn. mutation probability; number of spontaneous or induced mutations which take place in a random cell sample during a certain interval of time; see mutation. Mycoplasmas: previous term PPLO (pleuro-pneumonia-like organisms); bacteria-like microbes without cell membrane of the family Mycoplasmataceae. The species Mycoplasma hominis and Ureaplasma urealyticum are frequently seen as commensals in the genital area; potentially pathogenic: Mycoplasma hominis can cause pelvic inflammatory disease, postpartum or post-abortive endometritis, while Ureaplasma urealyticum can cause urethritis and probably prostatitis. Morphology: due to the absent cell membrane, there are various shapes, and affinity to stains is poor. Culture: demonstration by culture on protein-rich (horse serum) culture medium (e.g. Shepard A7); evaluation of the minute colonies by microscope: Mycoplasma hominis colonies demonstrate characteristic fried-egg shape. Ureaplasma urealyticum colonies grow without halo and can be diagnosed by establishing evidence of urea metabolism with an indicator (typical for this organism). Serology: in urogenital infections, clinically not significant.

Mycoplasma hominis: see Mycoplasmas, mycoses, genital: fungal infections of the genital area; e.g. Candida* vulvovaginitis. myoma (Gr. mys, myos the mouse, muscle): uterus myoma; rarely solitary, usually benign tumor (leiomyoma, fibromyoma, also adenomyoma) of the myometrium of the uterus* (most frequent site of myomas), present in approximately 20% of all women after age 30. The growth of the myoma is clearly estrogen dependent (can be limited by antiestrogens*); eiftier the climacteric, usually slow regression

Myoma uteri: Histological cross-section of uterus and cervix; in the cervix a circular leiomyoma can be seen which causes lateral compression and deviation of the cervical canal. occurs. Due to the frequently multiple uterine myomas, the term uterus myomatosus is frequently used. Clinical classification: 1. localization: corpus myoma, rarely cervical myoma; 2. direction of growth: a) intramural (within the myometrium); b) submucous (in the direction of the uterine cavity); c) subserous (outer uterine wall under the serosa); d) intraligamentary (outside the uterus between the two layers of the ligamentum* latum uteri). The myoma only occasionally causes signs and symptoms: prolonged and increased menstruation*, occasionally metrorrhagia* (subsequently secondary anemia), dysmenorrhea*, pressure symptoms affecting the surrounding organs (among others dysuria, pollakisuria, constipation, rarely ileus), pain (usually associated with submucous myoma). Patients without symptoms should have regular examinations, In pregnancy, frequently rapid initial growth of the myoma with increased tendency towards degenerative changes occurs; increased risk of abortion, occasionally birth obstruction. Diagnosis: bimanual examination*, diagnostic ultrasound. Secondary benign degeneration of the myomas (in approximately 30%): degeneration (penetration with cavernous cystic spaces, edematous and myxomat163

myoma, intraligamentary ous changes, fatty degeneration, necrosis), rarely induration (calcification, fibrosis). Therapy: in general surgical (myomectomy*, hysterectomy*), however, also medication or hormonal treatment. Complications:torsion* (subserous myoma), septic necrosis with fever and purulent vaginal discharge* (submucosal myoma), change into sarcoma (rare); increased incidence of an endometrial carcinoma* in uterus myomatosus (differential diagnosis). myoma, intraligamentary: see myoma. myomectomy: "conservative myomec-

164

tomy"; excision of one or several uterine myomata with preservation of the uterus. myometritis: syn. (short form) metritis; infection of the myometrium; does not exist in isolation, but only as endomyometritis (see endometritis). myosarcoma (Gr. sarkoma meat tumor): malignant mesenchymal tumor (sarcoma) of the striated or smooth muscle; 1. the extremely rare (juvenile or adult) rhabdomyosarcoma; 2. the usually primary malignant leiomyosarcoma (may result from malignant changes in leiomyomas).

Ν

nabothian cyst (Martin Naboth, anatomist, Leipzig, 1675-1721): syn. nabothian* follicle. nabothian follicle: retention* cysts on the surface of the cervix; caused by overgrowth of glandular ducts from ectropionated cervical mucosa. Naegele's forceps (Franz Karl Naegele, obstetrician, Heidelberg, 1777-1851): this for-

tion starts in pregnancy or in the puerperium, frequently as part of eclampsia* or pre*-eclampsia or Couvelaire* uterus (uterine or placental apoplexy), which is usually associated with intrauterine* fetal death; other types of acute renal failure are also seen (with absent or incomplete reversal). Frequent result is the development of atrophic kidneys with ultimate renal insufficiency (uremia), and need for dialysis. Neisseria (first described by Albert Neisser, Breslau, 1855-1916): genus of gram-negative, non-motile diplococci of the family Neisseriaceae; oxidase-positive. Clinically of special interest: Neisseria gonorrhoeae, Neisseria meningitidis. Neisseria gonorrhoeae: s y n . g o n o c o c c u s ,

Naegele's forceps: a: cephalic curve; b: pelvic curve

ceps consists of two blades with pelvic curves; cf. forceps extraction, Kielland's forceps. Naegele's pelvis: oblique pelvis; a u n i -

lateral deformity of the sacrum, resulting in a pelvis narrowed in the oblique diameter; cf. pelvic types. Naegele's rule: serves as a clinical determination of the expected date of confinement or due* date: starting from the first day of the last menstruation*, three months are subtracted and seven days are added. natality: number of live births (see birth, live) per thousand inhabitants. native: term for the smooth epithelium of the normal surface of the cervix; see colposcopy. navel: see umbilicus, neck of the uterus: see cervix uteri,

necrolysis, toxic epidermal: s e v e r e c o u r s e

of staphylogenous Lyell's* syndrome in newborns and infants, described first by Ritter von Rittershain. necrosis, fatty: see fatty necrosis, necrosis, renal cortical: s y n . J u h e l - R e n o y

syndrome; extensive, usually bilateral necrosis of both renal cortices, except for a small subcapsular area. The medulla is rarely involved. Thrombosis of the arteriae corticales radiatae and the vasa afferentia are characteristic. Pathogenesis: multiple episodes of thrombosis by intravascular coagulation. Clinical manifestation: in two thirds of the cases the condi-

Gonococcus neisseri, Micrococcus gonorrhoeae; gonorrhea organism. Morphology: gram-negative bean-shaped diplococci; in smears they are usually intracellular in the cytoplasm of the leukocytes, and can be stained with methylene blue. Caveat: confusion with Sarcina* pseudogonorrhoeae. Damaged diplococci may be gram-labile due to antibiotic treatment. Confirmation of Neisseria gonorrhoeae in the smear can also be established by enzyme immuno-assay (EIA). Culture: gonococci require sophisticated culture media;

ilk Vji "

ΙΨ

φ

,φ

1

ig

Neisseria gonorrhoeae: Pus smear with methylene blue stain (left) and gram stain (right)

they grow on protein-containing media (serum·, ascites-, and blood agar; better ThayerMartin medium), which require a humid surface. Sensitive to low temperatures and oxygen, require special transport media; microaerophil, C0 2 -tension 5-10%; optimum temperature around 37 °C; growth after 24-72 hours; delicate round transparent colonies (dewlike). Culture is required for the correct diag165

neonatal mortality

nosis, since the gram preparation by itself is not adequate. Differentiation: biochemical; saccharolysis in Lingelsheim's medium; oxidase-positive: Serology: positive complement fixation test in chronic cases possible. Epidemiology: the reservoir for this organism is the human, with transmission by direct contact (sexual intercourse), rarely indirectly. neonatal mortality: fee infant mortality, neoplasia (Gr. neos new; plasma creation): new tissue formation; in a narrower sense autonomous excessive growth; clinically one understands neoplasia usually as a malignant occurrence; 1. homologous neoplasia: new tissue formation similar to its parent tissue; 2. heterologous neoplasia: parent tissue dissimilar. Further classification according to histomorphology and genesis, as well as according to degree of malignancy (e.g. International Histological Classification of Tumors, WHO). nephropathy: see proteinuria of pregnancy, nervus pelvicus: see nervi splanchnici pelvini. nervus pudendus: S(2)3-S4, 'plexus pudendus; — > through the foramen infrapiriforme, around the spina ischiadica, through the foramen ischiadicum minus in the fossa ischiorectalis, in Alcock's canal; - - > nn. rectales inff, perineales ( - - > nn. labiales-scrotales-posteriores), n. dorsalis clitoridis (penis); innervation: skin of anal region, of perineum, of the labia majora (of the scrotum), of the penis, m. sphincter anis ext., ischiocavernosus, bulbospongiosus, transversus perinei superficialis and profundus, corpus cavernosum, anterior urethra. Cf. anesthesia, pudendal. nervi rectales inferiores: nerves to the in-

ferior rectal and anal area, branching off after the junction of parts of the plexus sacralis with the nervi splanchnici pelvini to plexus pudendalis. nervi spinales: nerves of spinal cord; normally 31 pairs: bilaterally 8 nerves of the neck (nervi cervicales), 12 nerves of the thorax (nervi thoracici), 5 nerves of the lower back (nervi lumbales), 5 sacral nerves (nervi sacrales), 1 nervus coccygeus. Each originates through the joining of the sensory posterior root (radix dorsalis), which includes the spinal ganglion, with the motor anterior root (radix ventralis), which also carries autonomic (sympathetic) fibres. The short stems of the mixed nn. spinales leave the spinal canal through the intervertebral openings (foramina intervertebralia), where they divide into four branches: ramus meningeus, ramus ventralis, dorsalis, and communicans. The first cervical nerve exits between skull and atlas, the following six above their respective cervical vertebra, the eighth exits between the seventh cervical and first thoracical vertebra, the other spinal nerves leave below their respective vertebra. nervi splanchnici pelvini: syn. nervi eri-

gentes, nervi pelvici; sacral parasympathetic parts leading to the plexus hypogastrics inferior and the plexus uterovaginalis. nervi vaginales: branches of the plexus uterovaginalis leading to the vagina; innervation: vagina. 166

neuralgia, pudendal: term for localized tenderness in the pudendal area. newborn: live born infant (see birth, live) from the first breath (cry) to the completed age of four weeks. In relation to gestational period* and due* date, the newborns can be digrams

5000 Η

macrosomic for gestational age (hypertrophic) % go

/ 7

normal

/ w e i g h t for 5 0 gestational age 10 N ^(eutrophic)

below the weight gestational age (small-for-dates)

gestational weeks immature mature post-mature (equals preterm) (equals term) (equals past-term)

Newborn: Classification according to gestational age and birth weight

vided into severed groups: 1. delivered before term (preterm, premature): gestational period less than 37 completed weeks p.m. (less than 259 days); 2. at term (term, mature): gestational period more than 37 completed weeks and up to 42 completed weeks (259-293 days); 3. born after term (post-term, post-mature): gestational period 42 completed weeks and beyond (294 days and longer). In relation to birth weight the following weight groups are separated: 1. low birth weight (birth weight less than 2500 grams); 2. normal weight range (birth weight between 2500-4500 grams); 3. macrosomic (birth weight above 4500 grams). The development of the newborn is determined from gestational age and birth weight with the help of weight distribution curves (see Fig.). If the weight for a specific gestational age falls within the 10th to 90th percentile, then this newborn will be called eutrophic. If the weight is below the 10th percentile, it is called smallfor-dates infant* or hypotrophic. If the weight is above the 90th percentile, the infant is called macrosomic (large-for-dates infant*, hypertrophic). Intrauterine life (parenteral nutrition and transplacental respiration) is terminated with the clamping of the umbilical cord. During birth birth* trauma can occur. The neonatal period* is marked by the transition from intra- to extrauterine life. The neonatal adaptation* with the sudden transfer of placental functions to the functionally immature organs (skin, lungs, liver, kidneys, stomach, bowel, central nervous system), and the con-

nipple version of circulation* characterize the physiological requirements of this period; physiological weight loss in the first 5 days of approximately 10% of the birth weight is normal; temperature fluctuations are due to the incompletely functioning temperature regulation; the superficial and occasionally irregular respiration is dependent on the maturation of the bulbar breathing center and the development of the pulmonary functions; physiological icterus* neonatorum is due to relative liver immaturity; edema and acidosis are due to decreased renal function; slow adjustment of the GI tract (capacity, digestive enzymes, reabsorption) to oral food intake is necessary; primitive reflexes* are present due to absence of cerebral and corticospinal tract functions as an indicator of CNS immaturity; transition of the cardiovascular system to the adult type occurs, as well as glycosuria. Due to these predisposing factors, the newborn is at risk for specific diseases. So-called adjustment disturbances are complications of the adjustment and transitional processes in the newborn (e.g. dehydration, neonatal hyperbilirubinemia*, hemorrhagic* disease of the newborn, edema, neonatal tetany*, nutritional disorders). In addition, anomalies of the umbilical cord insertion and already recognizable malformation* syndromes belong to this group; furthermore, the newborn may be subject to a series of specific infections (pemphigus* neonatorum, toxic epidermal necrolysis*, gonococcal conjunctivitis*, inclusion* conjunctivitis, neonatal sepsis, neonatal herpes* sepsis). Cf. assessment, neonatal. newborn, hemorrhagic disorders of: see hemorrhagic disorders of the newborn. newborn, high-risk: newborn with signs or risk factors which indicate an increased risk: 1. newborn after intrauterine primary metabolic acidosis*; 2. neonatal depression* (APG A R < 6, Saling's score < 6); small-for-dates infant*, large-for-dates infant*; 4. newborn of a pregnancy with moderate or severe pre-eclampsia or postmaturity* (postmaturity* syndrome); 5. newborn after cesarean* section, operative delivery*, or delivery as breech; 6. erythroblastosis* neonatorum (newborn with icterus praecox); 7. placenta* praevia, abruptio* placentae; 8. multiple pregnancy*; 9. infant of a diabetic mother; 10. newborn with amniotic* infection syndrome. newborn, reflexes: see reflexes, primitive.

nicotine: (S)-3-(l-methyl-2-pyrrolidinyl)pyridine (IUPAC); CAS-No. 54-11-5; C10H14N2; molecular weight 162.23; an alkaloid in the tobacco plant (nicotiana tabacum; see also tobacco); at low concentrations has a stimulatory action, at higher concentrations a paralyzing action on the postsynaptic membrane of the ganglia (ganglion blocker); fatal dose about 1 mg/kg BW, contained in 3-5 cigarettes. 30% of this is found in the smoke, with the following amounts being absorbed: 5% when cigarettes are smoked without inhaling, 70% with moderate inhalation, 95% with deep inhalation, and 60%, when cigars are smoked without inhaling. Nicotine is broken down rapidly in the body (half-life 2 hr.). Habituation develops with repeated intake (smokers two- to threetimes less sensitive than non-smokers); absorption via the skin also possible. In acute intoxication circulatory collapse, vomiting, diarrhea, seizures, respiratory paralysis. In chronic intoxication (smoking) obliterating vascular disease (smoker's leg), promotion of arteriosclerosis and coronary diseases, gastrointestinal disorders. In pregnancy, a relationship has been demonstrated between the mother's intake of nicotine and the incidence of small-for-dates births (see Table). Nicotine passes into the breast* milk. nidation (Lat. nidus nest): the embedding of the fertilized ovum in the mucous membrane of the uterus (or of the tube); cf. implantation. nidation blockers: drugs which do not prevent conception* but rather nidation*. Use: 1. as a prophylactic measure for the purpose of contraception* (see contraceptive devices, intrauterine); 2. as an emergency measure when unwanted conception presumably has occurred (so-called postcoital contraception*). nipple: papilla mammae, mamilla; located slightly below the center of the breast; a wrinkled pigmented protuberance surrounded by the areola* mammae, usually pointed slightly up- and outward. Close to the lighter nipple tip the 12-20 milk ducts (ductus* lactiferi) converge into the so-called milk pores. Vascular engorgement and the contraction of smooth muscles underneath the nipple and areola lead to erection of the nipple. Nursing can be made difficult by a very flat or inverted nipple*. Supernumerary nipples (hyperthelia) are found preferentially along the milk* line from the axilla to the inguinal region. Cf. breast, accessory.

Nicotine P e r c e n t a g e of small-for-dates births in relation to the s m o k i n g habits of mothers Study g r o u p s

Documented births

P e r c e n t a g e of small-for-dates births

Non-smokers Smokers occasionally up to 5 cigarettes/day 6 - 1 0 cigarettes/day o v e r 10 cigarettes/day

4235

8.5%

789 420 347 245

7.9% 10.9% 14.1% 16.7% 167

nipple adenomatosis nipple adenomatosis: reddening, infiltration, and erosion of the nipple, secondary to a benign adenoma. Differential diagnosis: Paget's disease, eczema, psoriasis. nipple, inverted: due to a discrepancy between the papillary and areolar musculature (primary, congenital inverted nipple), or due to an inverting process (secondary, acquired inverted nipple, specifically due to inflammatory changes, precancerous conditions or breast in patients with secondary (acquired) inverted nipples, carcinoma of the breast must always be excluded. carcinoma). Marked inverted nipple interferes with nursing*; in the primary form, nursing is possible with the use of a shield. Therapy: elfter exclusion of malignant conditions, plastic surgery is possible in the form of a nipple eversion procedure; nursing will not be possible afterwards, since this procedure includes division of the excretory ducts of the ductus lactiferi. nitrous oxide: dinitrogen oxide, N 2 0; odorless, non-explosive and incombustible gas with euphoristic properties. Non-toxic anesthetic, but 0 2 must be added in a concentration of at least 25 vol.% of the inspired air. Anesthetic potency slight, at 80 vol.% no deep anesthesia can be achieved; potent analgesic effect, therefore usually used as a mixed anesthetic with

volatile anesthetics and neuroleptanalgesia (NLA) for inhalation analgesia. Loss of consciousness is of rapid onset; does not influence the activity of the uterus and the response to oxytocin. Side effects: displaces nitrogen from blood and gas-filled body cavities and thereby causes, e.g. a rise in pressure in pneumatized hollow organs (inner ear, intestines, etc.). Noble's sign (George H. Noble, gynecologist, Atlanta, 1860-1932): pregnancy* sign after twelve weeks: reduction in size of the lateral vaginal fornices due to incorporation of the lower uterine segment by the gestational sac. no-effect level: see no-observed-effect level. N O E L value: abbr. for no*-observed-effect level. non-disjunction: insufficient division of homologous chromosomes in meiosis* (nondisjunction in its narrower definition) and mitosis* (so-called non-separation), in which two homologous chromosomes remain together where they should normally move to opposite poles of the nuclear spindle. Thus, during meiosis germ cells form with too many or too few chromosomes; if fertilization takes place, the zygote exhibits gene mutation. Cf. Klinefelter's syndrome, Turner's syndrome, Down's syndrome. nonoxynol 9 (INN-Ε): nonoxinolum (INNL), 4-nonylphenoxypoIyethyleneglycol (IUPAC); CAS-No. 9016-45-9; C33H60O10; molecular weight 616.83. Use: as active substance in lo-

Possible combinations of gonosomes following simple non-disjunction

168

nymphomania

cally applied chemical contraceptives; see spermicides. n o - o b s e r v e d - e f f e c t level: NOEL value, dose or concentration determined in animal experiments at which a damaging effect can no longer be demonstrated; is used, making use of a safety factor (usually 10 or 100), to establish the tolerable exposure for man, when no direct data are available for humans. N o o n a n ' s s y n d r o m e (Jacqueline Noonan, cardiologist, Lexington, born 1928): syn. pseudo-Ullrich-Turner syndrome, XX-Turner phenotype, XY-Turner phenotype; complex hereditary anomalies syndrome which is clinically similar to Turner's* syndrome, but without chromosomal aberrations; both sexes can be affected. Assumed to be relatively frequent (estimate 1:1000 live born infants). Etiology: unknown, although probably hereditary. Signs: similar to Turner's syndrome, with the following differences: less pronounced short stature, not always present; more frequent and more severe congenital cardiac* anomalies (specifically pulmonary valve and pulmonary artery stenosis), more frequent mild mental retardation, in boys cryptorchism or testicular aplasia (wide variation of gonadal function from normal fertility to complete agonadism), in girls normal, occasionally delayed menarche. norethindrone: syn. norethisterone*. norethisterone (INN-Ε): norethisteronum (INN-L), 17a-ethinyl-19-nor-testosterone (IUPAC); CAS-No. 68-22-4; C20H26O2; molecular weight 298.43; synthetic gestagen. Use: for oral hormonal contraception* alone (minipill) or in combination with estrogens, as norethisterone enanthate for parenteral inhibition of ovulaCH°H

Norethisterone

tion. Therapeutic use: orally as norethisterone or norethisterone acetate for endometrial transformation, in endometriosis, mastopathy, premenstrual syndrome, dysfunctional bleeding. norethynodrel: 17a-hydroxy-19-nor-17apregn-5(10)-en-20-yn-3-one; C2oH2e02; molecular weight 298.41; gestagen which is derived from 19-nortestosterone and is rapidly metabolized to norethisterone*; cf. gestagens.

norgestimate: synthetic gestagen which is derived from 19-nortestosterone and is used in oral contraceptives for hormonal contraception*. norgestrel (INN-Ε): norgestrelum (INN-L), (±)18-methyl-norethisterone (IUPAC); CASNo. 6533-00-2; C21H2802; molecular weight

CH,CH,P H ^R-C=CH

oXXJ

Norgestrel

312.44; synthetic gestagen. Use: as gestagen component in sequential preparations for hormonal contraception* and for the treatment of climacteric symptoms, cycle disorders, endometriosis, dysmenorrhea; cf. gestagens. N u c k ' s h y d r o c e l e (Anton Nuck, anatomist, 1650-1692): syn. hydrocele* feminae. nulligravida: woman who has never been pregnant; cf. history, obstetrical. nullipara: woman who has never given birth; cf. history, obstetrical: nursing: syn. breastfeeding; natural feeding of the newborn with breast* milk from the maternal breast. Prerequisite for nursing is the ability of the mother to nurse, which is present in more than 80% of cases. In some cases, nursing may be difficult or impossible due to psychological (doubt, indecisiveness, lack of preparation) or physiological nursing problems (inverted nipples, fissures, mastitis), or administration of medications that pass into the breast milk (see breast milk, Table). Maternal tuberculosis is considered an absolute contraindication for nursing (separation of mother and child, until the child is protected by BCG, approximately 6 weeks). Neonatal problems associated with nursing are less frequent (premature infant*, some illnesses of the newborn*). Prerequisite to an appropriate nursing technique is good instruction by a nurse, midwife, or physician. Before and after nursing, the nipple and surrounding area are cleaned thoroughly with sterilized water. Nursing attempts, particularly in the first days of life, require patience, until the newborn grabs the whole nipple with the mouth and applies strong suction (cf. reflexes, primitive; weaning, agalactia, hypogalactia, colostrum, demand feeding). n y m p h o m a n i a (Gr. nymph the bride; mania madness): term for hypersexuality* in women.

169

ο oblique lie: type of transverse lie*, obliquity: see asynclitism, obstetrics, psychosomatic: deals with the interrelationship between psychological and physical processes during pregnancy, birth, puerperium. Symptoms with possible psychogenesis are e.g. hyperemesis gravidarum, hypersalivation, pre-term labor, birth anxiety, lactation problems. Childbirth* preparation is helpful in the creation of an emotionally stable state. At the time of delivery, reduction of anxiety, presence of a trusted individual, pain relief, and early maternal-infant contact are important. A positive maternal-infant relationship should be promoted in the puerperium through rooming*-in, demand* feeding, the opportunity to have an ambulant delivery (i.e. hospital delivery, discharge within a few hours), as well as support in the initiation of nursing. obturator canal: see canalis obturatorius. obturator fascia: see fascia obturatoria. obturator foramen: see foramen obturatum. obturator m e m b r a n e : s e e m e m b r a n a o b -

turatoria.

occiput

occipital.

see

presentation:

presentation,

oifactogenital d y s p l a s i a : s e e dysplasia, o l -

factogenital. oligohydramnios (Gr. oligos little): also oligohydramnion; reduction of the volume of amniotic* fluid to below 100 ml. oligolactia: hypogalactia*, oligomenorrhea: infrequent menstruation of normal duration and amount with a cycle length of more than 35 days. Types: primary oligomenorrhea is present since menarche,

cycle flow

1.

2.

heavy

I

normal light

3.

!

4.

5.

6.

ι

i

Oligomenorrhea

while secondary oligomenorrhea occurs later; with oligohypomenorrhea the bleeding is lighter; with oligohypermenorrhea, it is heavier than in normal menstruation. Etiology: prolonged follicle maturation phase with corpus luteum phase of usually normal duration; anovulatory oligomenorrhea occurs also (tran-

sition to hypothalamic amenorrhea* possible). Diagnosis: among others, basal body temperature, vaginal cytology, exclusion of associated endocrine diseases (e.g. polycystic* ovaries syndrome), psychoanamnesis. Therapy: may not be necessary; hormone therapy depends on cause and indication (e.g. planning of pregnancy, symptomatic regulation of cycle). omphalitis (Gr. omphalos navel): inflammation of the navel and surrounding area in the newborn, may be associated with ulceration (ulcus umbilici) and gangrene with following necrosis of the surrounding abdominal wall. The development of a gangrene is identified by replacement of the navel by a large discolored ulcer. omphalocele: see hernia, umbilical cord, omphalomesenteric duct: see ductus o m -

phalomesentericus. oncogenes (Gr. onkos tumor): tumor-producing genes; genes with oncogenic potential are part of the normal somatic cell complement and may play a decisive role in the control of normal growth. They are important in the early embryonal phase, e.g. in the trophoblast of the placenta* for nidation* of the early embryo, for fetal nutritional supply, and endocrine and immunological changes of the maternal organism during pregnancy. Postpartum, these functions disappear by repression of the specific genes, however, they may reappear in tumor cells, according to the oncological gene regulation theory with modification in the regulation mechanisms between the operator and the regulator genes, or according to the mutation theory by direct modification of the operator gene. The oncogene hypothesis suggests that the intracellular^ located information which can cause malignant changes may be reactivated by oncogenic* viruses and other exogenous (chemical or physical) carcinogens, as well as by various endogenous factors (e.g. aging, hormones). oncogenic viruses: viruses with the ability to cause in vitro or in vivo neoplastic transformation of human and animal cells. Oncogenic characteristics were first noted in viruses in 1911 in the Rous sarcoma of the chicken. Since then, more than 100 different viruses with oncogenic potential have been found; they are all members of the families of viruses with double helix DNA or of the Retroviridae. Neoplasms due to viruses can occur only in immuno-incompetent organisms; the transformation may occur by disregulation of cellular oncogenes* or by transfer of foreign oncogenes into the cell. The following viruses are asso171

oncology

ciated with human tumor pathogenesis: herpes simplex II (carcinoma of the cervix), cytomegalovirus (carcinoma of the urogenital tract, Kaposi's sarcoma), human papilloma virus (carcinoma of the cervix), retrovirus (HTLV 1,2; human T-cell lymphoma). oncology (Gr. logos teachings): the seien« of tumor diseases. oocytes: syn. ovocytes; see ovum, oogenesis: also ovogenesis, development oi the ovum*; in the female embryo primordial germ cells (see gametogenesis) are differentiated to oogonia in the fifth week and multiply mitotically until the 5th month, at which time they reach their maximal number (c. 6 mill.). The majority of the oogonia will degenerate before birth, about 700,000 to 2 millions oogonia differentiate between the 3rd and 4th month to primary oocytes, which are in a „resting phase" at birth between prophase and metaphase of the first meiotic division (known as dictyotene stage), and form primary follicles surrounded by epithelium in tiie ovary. By the beginning of puberty the number of primary oocytes has been further reduced to c. 40,000. During the following years until menopause, about 400 of these complete the first meiotic division after follicular maturation* during the ovarian cycle*, resulting in a secondary oocyte and a first polar body. The second meiotic division starts immediately afterwards but will be completed only if fertilization occurs; cf. fertilization. oogonium (Gr. gone generation): primordial ovum; see oogenesis. oolemma (Gr. lemma cover): syn. membrana pellucida, zona pellucida, fetal membrane; membrane of extracellular glycoproteins which is formed by follicle cells of the ovary and surrounds the ovum*; cf. maturation, follicular. oophorectomy: operative removal of one (hemicastration) or two ovaries (castration*). oophoritis: inflammation of the ovaries; rarely isolated, usually associated with salpingitis* as a secondary infection, rarely primary. Infection usually ascending, but can be lymphogenous or hematogenous (e.g. in sepsis, as well as in peritonitis). Types: 1. most frequently parenchymatous (e.g. due to involvement of the follicle layer, formation of follicle and corpus luteum abscesses, or inflammatory atrophy); 2. exudative-interstitial type (serous, purulent, hemorrhagic); symptoms: same as in salpingitis. oophoron: ovary; ovarium*, orange-peel skin: see skin, orange peel, organogenesis (Gr. organon tool; genesis development): (embryol.) growth and differentiation of the cells of the trilaminar embryonic* disc into embryonal organ anlagen in the first 12 weeks of life (see Fig.). organs, genital: s e e genitals,

orgasm (Gr. orgaein to swell, burst): culmination and (usually) satisfaction of sexual excitement in association with sexual intercourse* or masturbation*; physiol. reactions: orgasm is associated with involuntary contractions of muscles especially in the genital area, but also in the entire body; increase in heart 172

hram pyp 1 ^ ^ r r y y y y y y y y y y y y x h οa η ι limhs 1 lear —

,

,

,

palate -vv^Jaliilnmpn

ι , gameto- h i s t o genesis genesis

development of the fetus

embryogenesis 4

6

8

conception

10 1 2 14 16 gestational weeks

Organogenesis: Time-table for the formation of anlage of selected organs

rate, blood pressure, respiratory rate and depth, and a variety of pronounced changes in consciousness; in men followed by a refractory phase with diminished sexual sensitivity (see sexual response). With onset of sexual maturation, orgasm is associated with ejaculation* in men; in women secretions from paraurethral glands can occasionally be observed (Gräfenberg's zone). Cf. anorgasmia; dysfunctions, sexual. orgasmic

disorders:

see

dysfunctions,

sexual. orgasm phase: see sexual response (Table), orifice, vaginal: see ostium vaginae,

os coccygis (Lat os, ossis bone): see coccyx, os of uterus (Lat os, oris mouth): changes in the os of the uterus in the phase preceding birth and at the onset of labor; see ripening, cervical; cervix score. os of uterus, external: ostium uteri (orificium uteri externum); see uterus. os of uterus, internal: orificium internum

canalis isthmi (orificium uteri internum); see uterus. os pubis: pubic bone; part of the os coxae. Parts: body, ramus inferior and superior, os sacrum: see sacrum,

oscillations: also fluctuations; short-term variability of the fetal heart rate, which is contraction-independent and seen with instantaneous fetal heart*-rate recording; depending on the degree of fluctuation (band width, amplitude) different types are identified which may be useful for the recognition of intrauterine fetal compromise, see Table. Further differentiation according to the frequency (number of oscillations per minute). Cf. cardiotocography. Osiander's

sign (Johann

F.

Oslander,

gynecologist, Göttingen, 1787-1855): pregnancy* sign; palpable pulsation at the base of the cervix in the 1st and 2nd months of pregnancy. ossification center: ossification

center

leading to enchondral ossification, e.g. in the epiphysis of the long tubular bones (Biclard ossification centers in the distal epiphysis of the femur). Forensically important for the determination of the age of fetuses or the corpses of children.

osteoporosis Oscillations Type of fluctuation of the fetal heart rate on the c a r d i o t o c o g r a m Type Term of oscillations

A m p l i t u d e of oscillations (FHR; beats per minute)

F r e q u e n c y of oscillations c h a n g e s of the F H R per minute)

2-25

Evaluation

>6

(rapid) normal

d III C undulatory

> 10 - < 25

possible cord compression Ills

limited undulatory

>5

silent

labia minora complete sole

Gestional age in weeks = 30 + score 184

pill pause Pfannenstiel's incision (Johann Pfannenstiel, gynecologist, Breslau, 1862-1909): socalled transverse fascia incision; skin, subcutaneous tissue, and fascia are incised transversely for cosmetic reasons (2-3 finger breadths above the symphysis pubis). PG: abbr. for prostaglandins*, phantom pregnancy: pseudopregnancy*. phase, hyperthermic: phase of elevated basal body* temperature in the second part of the cycle; corresponds to the corpus luteum phase of the female menstrual* cycle. The length of the hyperthermic phase is important for the determination of fertility* in the woman. Cf. cycle, biphasic. phase, luteal (Lat. luteus golden-yellow): corpus luteum phase of the menstrual* cycle. phenocopy (Gr. phainomai to appear): changes in the formation of a trait (phenogenesis) of a genotype influenced by external factors in close interplay with the specialized genetic disposition, which together lead to a copy of the manifestation pattern of another genotype. The resulting phenotypical modifications are not inherited, i.e. the genotype itself remains unchanged (see also diseases, genetic). Exogenous factors during pregnancy can lead to intrauterine developmental disturbances of various organs or organ systems of the child, if they have an effect before completion of the determining period, e.g. cataract (resulting from recessive inheritance or by rubella and/or radiation exposure during early pregnancy), warfarin embryopathy (clinically identical to genetically caused chondrodysplasia punctata). Cf. diseases, prenatal. phenotype: morphological appearance (in contrast to genotype*, set of inherited genes). Sum of all characteristics present in a single person, external image, outward appearance, functional traits which will be expressed in various ways by the genotype in interaction with environmental influences. The degree of the phenotypical manifestation is described by the expression. phlegmasia alba dolens: pelvic and femoral vein thrombosis, usually after parametritis puerperalis; swelling of the whole leg with severe tenderness, pallor, fever. Cf. parametritis. photocoagulation, infrared: technique for the outpatient treatment of benign conditions of the cervix, as well as control of bleeding from cervix, vagina, and vulva, associated with minimal discomfort. Technique: the focussed light of a wolfram halogen lamp (similar to laser beam) causes heat coagulation at approximately 100 °C. phototherapy (Gr. phos, photos light): light therapy for the treatment of hyperbilirubinemia* of the newborn. The effect is due to interaction of the (visible) light in the spectral range between 410 and 530 nm with bilirubin molecules in the skin of jaundiced newborns; isomerization changes water-insoluble indirect bilirubin* into soluble and easily excretable photo bilirubin. Although until recently, blue light was considered optimal, research indicates that green light is superior (also of less concern in view of the mutagenic effects on

cell cultures seen with blue light). Indications: moderate to severe hyperbilirubinemia; the etiology should be determined. Basic rule: begin phototherapy at concentrations of serum bilirubin of approximately Vio of the body weight in μπιοΐ/ΐ; but not more than 280 μπιοΐ/ΐ; should be initiated at lower serum bilirubin levels in the presence of hypoxia, acidosis, sepsis, etc. It can only be used in the presence of jaundice (not prophylactically). As much as possible of the body surface should be radiated (simultaneously from above and below, socalled double phototherapy); neonates should be close to the light source (control of temperature and increase in fluids necessary since insensible fluid loss increases). Careful monitoring of the newborn. Change to intermittent treatment when serum bilirubin concentration decreases. Phototherapy will reduce the number of exchange transfusions. Caveat: do not use phototherapy in neonates with direct hyperbilirubinemia; risk of development of so-called bronze-baby syndrome (grey discoloration of the skin). phrenic nerve palsy: unilateral palsy of the diaphragm, either congenital, or due to birth trauma, the latter often in combination with damage to the plexus brachialis (brachial plexus* palsy), specifically after forceps extraction or breech delivery -due to damage to the third and fourth cervical root. Signs: dyspnea, cyanosis, sunken abdomen, irregular bowel movements; after trauma frequently swelling of the affected side of the neck. Diagnosis: radiologically unilateral elevation of the diaphragm with paradoxical movements (Kienböck's sign); frequently atelectasis of the lung. Phthirus pubis (Gr. phteir louse): syn. Phthirus inguinalis, pubic louse. See lice. physometra (Gr. physa meteorism): syn. tympania uteri; gas formation in the uterus in patients with acute, usually lethal sepsis, e.g. in neglected transverse lie* (extremely rare). Pierre-Robin syndrome (Pierre Robin, dentist, Paris, 1867-1950): congenital anomaly of unknown origin associated with microgenia, glossoptosis, also possible microglossia and cleft palate, frequently combined with other organ abnormalities; high neonatal mortality due to breathing problems. Immediate treatment consists of intermittent wire extension of the mandible, by placement of the wire in the middle of the mandible. pigmentation of pregnancy: the deposition of melanin on face (see chloasma gravidarum), nipples, linea alba, vulva, and anus in pregnancy. Cf. stretch marks. PI Η : abbr. for prolactin inhibiting hormone, prolactostatin; peptide of unknown structure originating from the hypothalamus and possibly identical with dopamine, inhibits the release of prolactin* from the anterior pituitary lobe; cf. releasing hormones, piles: syn. hemorrhoids*, pill pause: in the past a pill pause was recommended after 6-12 months use of oral contraceptives (see contracption, hormonal) to identify persistent menstruation* disorders 185

Pinard's s i g n

after discontinuation of the pill (post-pill amenorrhea*); now considered unnecessary since it does not decrease the frequency of secondary amenorrhea elfter discontinuation of the pill; besides, many women had unplanned pregnancies, and the use of modern low-dose oral contraception results in the establishment of normal hormone production and normal menstruation cycles shortly after discontinuation. Pinard's sign (Adolphe Pinard, gynecologist, Paris, 1844-1934): pregnancy* sign, usually not before 16 weeks gestation: at bimanual examination a gentle push of the uterus from the vaginal finger will result in a typical passive movement of the fetus in the amniotic fluid. Piskacek's sign (Ludwig Piskacek, gynecologist, Vienna, 1854-1932): asymmetrical change in the shape of the uterus in pregnancy (see pregnancy signs): the area of the fundus where implantation has occurred is more prominent, due to localized hormonally based hyperemia. pituitary gland: s e e h y p o p h y s i s .

placenta (Lat cake): afterbirth (because it is expelled after the birth of the fetus); saucer-shaped organ of 15-20 cm diameter, 2-4 cm thickness, and about 500 g weight. Localization: normally high in the fundus on the anterior or posterior wall of the uterine body. Structure: the basis for the fetal section (pars fetalis) is the chorion which is covered on the fetal side by the glossy-smooth amnion and is the site of attachment of the umbilical cord. The branched villous stems, which branch out from the uterine side of the chorion plate into numerous chorionic villi, connect to the maternal part (pars materna or uterina), the decidua basalis (basal plate), which is attached to the uterine wall. The placental septa, which originate from the basal plate, divide the organ into 15-20 knobby regions (cotyledons). The space between the villi (intervillous space) is perfused by maternal blood: placenta hemochorialis, i.e., the fetal chorion villi (containing fetal blood vessels) are submerged in maternal blood; however, there is no direct communication between maternal and fetal circulations (placental* barrier). Function of the placenta: fetal nutrition (the placenta is the organ of exchange of metabolic products and gases between maternal and fetal blood), endocrine gland (see hormones, placental). Cf. cotyledon, placental; unit, feto-placental; insufficiency, placental; placentation disorders. placenta accreta: villi of the placenta* are

SSS^

firmly attached to the myometrium (see Fig.); see implantation disorders. placenta, adherent: adherent placenta which does not separate spontaneously (Fig.); cf. placental separation, anomalies.

placenta, annular: ring placenta; due to absence of decidua spongiosa and decidua compacta, the central portion of the placenta is sclerosed. placenta, battledore: placenta marginata, placenta extrachorialis; developmental abnormality of the placenta*; the villi outside the chorionic plate have grown around the edge of the placenta. The fetal membranes* are not attached at the edge of the placenta but more centrally. placenta bilobata: also placenta bipartita, lobular placenta; anomaly of the placental shape due to nidation laterally in the uterus, and placental implantation anteriorly, as well as posteriorly; two (or three, so-called placenta trilobata, or more, so-called placenta multilobata) placental lobes can develop. placenta bipartita: syn. placenta* bilobata.

placenta, cervical: placenta praevia cervicalis; rare type of placenta* praevia: the placenta is implanted in the cervical canal (Fig.). placenta circumvallata: more pronounced than placenta* marginata, with circular pocket formation of the membranes and raised placental edge. placenta f e n e s t r a t e : a n o m a l y o f t h e p l a -

cental shape, not associated with increased fetal risk. placenta, incarcerated: i m p a c t i o n o f t h e

separated placenta due to contraction of the cervix; cf. dystocia, cervical. Placenta accreta 186

placenta increta: the villi of the placenta*

are grown into the myometrium; see implantation disorders.

placental separation, a n o m a l i e s o f placenta, manual r e m o v a l of: i n d i c a t e d i n

the presence of anomalies of placental* separation (see Fig.); cf. Crede's maneuver. placenta marginata: battledore placenta* with circular whitish fibrin streak corresponding to the site implantation; the fetal surface is smaller than the maternal surface. placenta membranacea: structural anomaly of the placenta*; the placenta is very thin, potentially compromising the transfer of nutrients to the fetus. placenta, multilobata: see placenta bilobata. placenta percreta: villi of t h e placenta* have grown through the myometrium to the serosa; see implantation disorders. placenta praevia: atypical localization of the placenta* in the lower uterine segment; the placenta covers the inner wall of the lower uterine segment to a varying e x t e n t Four degrees are defined, with the cervix 3 cm dilated: 1. placenta praevia totalis: the internal cervical os is completely covered. If the central portion of the placenta covers the internal os, it is called placenta praevia centralis; 2. placenta praevia partialis: the internal os is partially covered by the placenta. 3. placenta praevia marginalia: the lower edge of the placenta is at the edge of the internal os. 4. low lying placenta: t h e lower edge of the placenta does not reach the internal os. Occurrence: in multi- and grand multparae, especially if deliveries or curettages have occurred in close sequence.

Placenta praevia: 1: total; 2: partial; 3: marginal; 4: low-lying; 5: normal; a: body; b: lower segment; c: cervix

Signs: the cardinal sign is bleeding which can occur ante- or intrapartum, placing the mother at significant risk (maternal bleeding from the intervillous space); the fetus is also threatened (laceration of villi). Differential diagnosis: among others, abruptio* placentae, carcinoma of the cervix, cervical polyp. Danger of placenta praevia: 1. to the mother: severe hemorrhage may lead to death, infec-

tion with risk of sepsis, air embolus (lethal, rare!); 2. to the child: hypoxia, post-hemorrhagic shock, exsanguination. Cf. cervical placenta. Placenta praevia means extreme danger of death by exsanguination for mother and child! placenta, retained: delayed expulsion of the placenta; cf. placental separation, anomalies of. placenta, succenturiate: a second separate placenta, caused by division of the placenta; cf. membranes, fetal. placental barrier: biol. barrier to corpuscular and large molecular particles between the maternal and fetal blood; passage across the placenta depends, among other factors, upon the molecular size of t h e particles, their protein binding, lipid solubility, t h e degree of dissociation, and electrical charge. Besides diffusion, there are also active transport mechanisms. placental cell e m b o l i s m :

see

embolism,

parenchymal.

placental lactogen: s e e H P L .

placental localization: d e t e r m i n a t i o n

of

the location of the placenta on the uterine wall. Two methods: 1. diagnostic ultrasound, the method of choice, can be rapidly performed without risk; A-, B-scan, and real-time ultrasound can be used. Location, distribution, and thickness of the placenta can be determined. 2. in the past, placental scintigraphy. Indications: 1. antepartum hemorrhage after 20 weeks (suspicion of low-lying placenta, placenta* praevia, or placental* separation); 2, before amniocentesis*. Cf. placental thickness measurement, intrauterine. placental remnants: retained products in the uterine cavity after expulsion of the placenta; risk of postpartum hemorrhage*, infection, as well as development of malignant chorioepithelioma*. An incomplete or torn placenta (e.g. accessory lobe) points to retained products. If in doubt, intrauterine exploration is indicated. Cf. polyp, placental. placental retention: delayed e x p u l s i o n of the placenta; cf. placental separation, anomalies of; placenta, incarcerated. placental separation: physiological separation of the placenta by contraction and reThe greatest risk of the premature separation of a normally implanted placenta lies in its frequent association with coagulopathies with partial or complete depletion of fibrinogen (hypo-, afibrinogenemia). traction of the uterus after delivery of t h e fetus (after-pains); Schultze's* or Duncan's* mechanism; cf. hematoma, retroplacental. placental separation, a n o m a l i e s o f : t h e

separation of the placenta can be associated 187

placental separation, s i g n s of placentation

Placental separation: Removal of a retained placenta

with a variety of problems which can delay the third stage (retained placenta*) or cause increased separation* bleeding. Delayed placental separation is present, if Elfter 30 minutes there are no signs of separation (see cord lengthening). Etiology: functional (uterine atony with adherent placenta*); anatomicpathological (morbid adherence of the placenta to the implantation site; see implantation disorders). Differential diagnosis: incarcerated placenta* with cervical dystocia. Therapy: oxytocic agents, bladder emptying, Crede's* maneuver, or manual removal of the placenta. placental separation, s i g n s of: see cord

signs.

placental

thickness

measurement,

in-

trauterine: measurement of the thickness of the placenta by ultrasound* diagnosis; abnormal increase in the thickness in severe cases of erythroblastosis* fetalis, with rapid increase in thickness in developing hydrops fetalis, and threatened intrauterine* fetal death (alarm sign and indication for fetal intrauterine transfusion or induction of labor). placentation: development and implantation of the placenta*; the development of the villi, the intervillous space, and the fetal-maternal vascular relationship. Two phases: 1. development of the chorionic villi to the secondary villi; 2. maturation of the tertiary villi (replacement of mesenchyme by capillaries). Occasionally, the villi can grow to the level of the myometrium (placenta* accreta), into the myometrium (placenta* increta), or through the myometrium to the uterine serosa (placenta* percreta). Etiology: frequently previous damage to the endometrium with subsequent atrophy (curettage, termination, cesarean section, endometritis). See placentation disorders; placental separation, anomalies of. Placentation in the lower segment of the uterus results in placenta* praevia. 188

disorders:

qualitative

and

time-related deviations in the formation and maturation of the villi. Types: 1. arrest of maturation: generalized delay in maturation (occasionally with abnormal differentiation) in the first trimester. Special type: chorangiomatosis placentae (abnormal differentiation of the mesenchyme: capillary proliferation). 2. retardation in maturation: maturation delay of all structures of the villi in the second trimester. 3. dissociation in maturation of villi: partially delayed, partially accelerated maturation of villi in various areas of the placenta. 4. compensatory deviation of maturation: segmental accelerated (premature and excessive) maturation of villi. Teratology: comparison between the critical phase of a specific anomaly and associated disturbance in placentation. 1. harmonious cyemopathy: synchronism of the arrest of placental maturation and of Vitium primae formationis (e.g. persistence of embryonic structure of villi and dorsal dysraphia). 2. dysharmonious cyemopathy: initial disturbance of placentäl maturation with subsequent fetal anomaly (in diabetic mothers; e.g. persistence of embryonic villous structures, and anomalies of the extremities and the GI tract). 3. primary embryopathy: developmental anomalies which develop only in the fetus (by transplacental transmission of a teratogen; e.g. rubella embryopathy). 4. complex anomalies syndrome: partially advanced, partially delayed disturbances in the placental development with combination of primary and secondary developmental abnormalities of the fetus (e.g. dysmelia syndrome). placentopathy: terminal state of disturbance in maturation of the placenta; e.g. in diabetes mellitus, erythroblastosis* fetalis, syphilis connata. plane (Lat. planus flat): surface; (obst.) the pelvic plane through which the head descends through labor and delivery. See skull measurements. planes, pelvic: 1. U-plane: upper symphysis pubis plane, pelvic inlet plane; 2. L-plane: lower symphysis pelvis plane; 3. I-plane: interspinal plane; 4. PO: pelvic outlet plane. plateauing: important sign which points to a malignant process in the female breast; infil-

Wk Pelvic planes: Median sagittal section through the pelvis with the classical planes; the pelvic axis is indicated by an arrow. 1: pelvic entrance; 2: widest plane of the pelvis (mid pelvis); 3: narrowest part of the pelvis; 4: pelvic outlet

polycythemia, neonatal

tration of the retinacula cutis causes unrounding of the mamma (plateau formation). In the early stage of a breast* carcinoma it is possible to demonstrate a plateau-like depression by concentric pressure of the skin over the palpable mass (diagnostic test of Jackson). plateau phase: see sexual response (Table), plexus mesentericus inferior (Lat. p l e x u s

network): nerve plexus with sympathetic nerve fibres from the plexus aorticus abdominalis and parts of the sacral parasympathetic system which accompany the branches of the a. mesenterica inferior. plexus

mesentericus

superior:

nerve

plexus along branches of the a. mesenterica superior with sympathetic nerve fibres from the plexus coeliacus and parasympathetic parts of the n. vagus. plexus

palsy,

brachial: d a m a g e

to

the

plexus cervicobrachialis; 1. upper brachial plexus palsy (Erb's or Erb-Duchenne palsy, C4-C6): palsy of raising, turning out, and flexing of the arm, raising of the shoulder, paralysis of the diaphragm (C4) and loss of sensation on the outside of the upper arm; 2. middle brachial plexus palsy (C5-C6): paralysis of extension of elbow and fingers, raising of hand; 3. lower brachial plexus palsy (Klumpke's or Dejerine-Klumpke paralysis, C8-Thl, occasionally C7): paralysis of finger movements, occasionally combined with Horner's syndrome. Etiology: birth trauma (e.g. breech), accidents (frequently motorcycle) fractures of the clavicle, after radiation for breast carcinoma, after serum sickness, etc. Cf. birth palsy. plexus rectalis inferior: a u t o n o m i c n e r v e

plexus; — > along the branches of the a. rectalis inferior, bilaterally to the anus. plexus rectalis medius: c o n t i n u a t i o n of t h e

nerve fibres of the plexus h y p o g a s t r i c s inferior (plexus pelvinus); > with branches of the aa. rectales mediae to both sides of the rectum. plexus rectalis superior: nerve plexus with sympathetic fibres derived from the plexus mesentericus inferior including sacral parasympathetic parts for supply of the rectum. plicae rectouterinae (Lat. plica fold): peritoneal folds between the rectum and uterus; lateral boundary of the Douglas'* pouch. plicae tubariae: highly ramified longitudinal folds of the mucosa of the fallopian* tube. plurigravida (Lat. plus larger, more frequent): woman who has been pregnant several times (2-5 times); cf. history, obstetrical. pluripara: woman who has had 2-5 children; cf. history, obstetrical. p.m.: abbr. for 1. post mortem: after death; 2. punctum maximum: area of loudest sound volume on auscultation; 3. post menstruationem: after beginning of menstruation. PMSG: abbr. for pregnant mare's serum gonadotropin, see serum gonadotrophin. pneumoperitoneum (Gr. pneuma breath, breath of life): collection of gas in the peritoneal cavity. 1. pathological pneumoperitoneum, e.g. due to traumatic air collection in the abdominal cavity or infection with gas-forming bacteria, after stomach or bowel perforation, Pertubation. 2. insufflation of gas into the

abdominal cavity to raise the abdominal wall for a diagnostic or therapeutic laparoscopy* or a pelvioscopy*.

Poland's syndrome (Alfred Poland, s u r -

geon, London, 1820-1872): complex malformation of the brachydactyly- and mammorenal syndromes. Etiology: probably hereditary, pattern of transmission still unclear. Signs: unilateral anomaly of the hand (syndactyly, synbrachydactyly), homolateral aplasia of the pectoral muscle, and facultative unilateral hypo- or aplasia of the nipple or breast, in this case frequently associated with hypo- or aplasia of the homolateral kidney. pollutiones feminae: so-called f e m a l e pol-

lutions; secretion of Bartholin's glands during sexual excitation in women in the late excitement phase (see sexual response); not identical with so-called female ejaculation during orgasm (cf. Gräfenberg's zone). polycystic ovaries syndrome ( G r .

poly

many, multiple): also PCO syndrome, previously Stein-Leventhal syndrome; it is defined by the triad: 1. bilateral or unilateral polycystic ovaries; often only identified by laparotomy or histology. The ovaries may be 3-4 times larger than normal, the surface is greywhite. In the cortex are multiple follicles; the capsule (tunica albuginea) is thickened, the medulla is hyperplastic. 2. (anovulatory) amenorrhea or oligomenorrhea; anomalies of the cycle are also possible (dysfunctional bleeding, etc). 3. infertility. The LH/FSH ratio is usually elevated. The androgens are only slightly elevated and are of ovarian or adrenal origin (frequently combined). Besides disturbances of the estrogen/androgen balance with signs of androgen excess (e.g. hirsutism), sexual disturbances, obesity, and hypoplasia of the genitalia can occur frequently. The etiology is unclear. Nearly always a normal karyotype, but chromosome anomalies have been noted (XX/ XY mosaic, XXX) Caveat: on a long-term basis, there is an increased risk of carcinoma of the endometrium. Therapy: 1. hormonal: by suppression of LH and androgen production (e.g. with cyproterone acetate); ovulation* induction and possibly steroids are indicated, if pregnancy is planned. 2. surgical: wedge resection of the ovaries; in addition (if possible) weight reduction; cf. hyperthecosis. polycystic syndrome, fetal: s y n . P o t t e r ' s

syndrome II; multiple cysts in kidney, liver, and pancreas of the newborn; congenital hyperplasia. Etiology unknown, frequently in combination with other abnormalities. polycythemia, neonatal: a h e a l t h y

new-

born* compared to older children and adults has a higher erythrocyte count (5.5 mil/μΐ) and a higher hematocrit (up to 60%). Under specific conditions (intrauterine dehydration in postmaturity, reactive increase in blood production secondary to placental insufficiency, excessive placental transfusion after late clamping of the cord, or maternal-fetal transfusion), a pathological neonatal polycythemia may occur with hematocrit values above 70% and hemoglobin above 23 g/100 ml. Life-threatening hemodynamic complications due to the relative de189

polyembryoma crease in plasma volume, as well as hypocalcemia or hypoglycemia, may be associated. polyembryoma: very rare germ cell tumor of the ovary in young women; originating from pluripotent malignant embryonic cells which differentiate teratogenically to small embryos. Contains histologically multiple primordia with embryonal disc, small amniotic cavity, and yolk sac. Teratogenic structures are occurring. The tumor is highly malignant, the prognosis poor. See tumors, ovarian. polyhydramnios (Gr. hydor water): also Polyhydramnion; abnormally increased volume of the amniotic* fluid above 2000 ml. polymastia: corresponds according to current clinical usage to ectopic breast*; cf. polythelia. polymenorrhea: too frequent menstruation of normal amount and duration; the cycle interval is decreased to less than 25 days. Type I: biphasic cycle with shortened follicle maturation phase; Type II: biphasic cycle with shortened corpus luteum phase; Type III: anovulatory cycle* (monophasic, hypothermal), the bleeding corresponds to follicle withdrawal bleeding. Diagnosis: among others, measurement of the basal body temperature, vaginal cytology, evaluation of the cervical mucus, possibly hormone assays. Therapy: hormone substitution, especially if anemia is present (due to frequent periods), and if pregnancy is planned in patients with functional sterility* related to polymenorrhea. polyp, anal (Gr. polypous morbid excrescence): polyp developed from papillitis hypertrophicans from below the linea dentata. polyp, cervical: usually a benign growth (hyperplasia) of the mucous membrane of the cervix; corresponds in structure and development to an endometrial polyp*. Signs: increased secretion of the glands of the cervical canal (mucoid vaginal discharge) or purulent hemorrhagic vaginal discharge* (spotting). If the polyp develops in the lower part of the cervical canal or in an ectropion of the cervical mucosa, it may reach the vaginal surface of the cervix partially or completely, and be covered secondarily by squamous cell epithelium (polyp of the external os). polyp, endometrial: also endometrial adenoma; circumscribed, usually benign polypoid hyperplasia of the endometrium; it originates from the basal layer of the endometrium* and consists of proliferating glands and dense stroma which is not shed at the time of menstruation*, due to deficiency in progesterone receptors, and therefore can reach a considerable size. Signs and symptoms: uterine bleeding, purulent or hemorrhagic vaginal discharge*, labor-like pain. Therapy: curettage* and histology (rarely adenocarcinoma). Differential diagnosis: cystic-glandular hyperplasia*. polyp, placental: after incomplete expulsion of the placenta placental remnants may be retained which are surrounded by blood clots. Consequence: endometritis, postpartum hemorrhage, occasionally inhibition of lactation. Cf. placental remnants. polyp, urethral: syn. urethral caruncle; be190

2-5

>5

Hypertension systolic diastolic

140-160

>160-180

>180




>100-110

>110

90

90-100

3 points

The pre-eclampsia index is a sum of all points (maximum 11). 193

pregnancy-associated glycoproteins follicle

corpus luteum

endometrium

Pregnancy: Changes of the endometrium and the ovary in early pregnancy: a: growing; b: mature; c: ruptured; d: formation; e: ripe; f: corpus luteum gravidatis; g: obstructive plug; h: embryo A: desquamation; B: proliferation; C: secretion; D: pregnancy

pregnancy, high-risk: pregnancy, with risk to the fetus and/or the mother. Incidence: approximately 30% of all pregnancies. Risk factors in pregnancy are: 1. preeclampsia; 2. postmaturity*; 3. erythroblastosis* fetalis; 4. diabetes* mellitus (overt or gestational); 5. threatened premature delivery*, preterm labor (including cervical incompetence); 6. poor obstetrical history, including previous preterm deliveries, stillbirths, cesarean sections, or difficult forceps or vacuum deliveries; 7. elderly primipara (after age 30), multipara (after age 40), young primipara (below age 20); 8. medical diseases; 9. severe anemia of pregnancy* (hemoglobin below 8 g/dl); 10. malposition* (breech, transverse lie), cephalopelvic disproportion, abnormal pelvis, multiple pregnancy; 11. obesity; 12. infectious diseases; 13. disproportion between uterine growth and duration of pregnancy; 14. hemorrhage in the second part of pregnancy. pregnancy, interstitial: implantation of

dicitis in pregnancy, immediate surgery is indicated. pregnancy-associated

glycoproteins:

proteins formed only during pregnancy in the maternal body or the placenta; e.g. a pregnancy-associated cij-glycoprotein (PAG*) and a ß r glycoprotein (SP-1) produced in the placenta, the levels of which rise in the serum and urine during pregnancy; decreased values in early pregnancy indicate threatened abortion. SP-1 may be a tumor* marker in male patients with malignant testicular tumors. pregnancy, bacteriuria of: bacteriuria*

occurs in c. 10% of all pregnant women. Routine urine cultures are recommended, since they also identify asymptomatic bacteriuria. In view of the increased risk of ascending urinary tract infections (see cystitis, pyelonephritis gravidarum), antibiotic treatment (watch for contraindications!) for 7-10 days is indicated elfter a specimen for urine culture has been obtained (most frequent organism: E. coli). pregnancy, duration of: see period, gestational. pregnancy, ectopic: see pregnancy, ex-

trauterine.

the fertilized ovum in the intrauterine part of the tube; rare type of tubal pregnancy; see pregnancy, tubal. pregnancy, multiple: two or more fetuses with synchronous intrauterine development: twins*, triplets, quadruplets, etc. During pregnancy they are at a disadvantage to a single pregnancy; intrauterine growth decreases early, in twins after 34 weeks, in triplets and quadruplets after 28 weeks (small-for-dates babies). Perinatal risk is increased, with increased morbidity and mortality rates; cf. newborn, high-risk; Hellin's rule. pregnancy, ovarian: extrauterine pregnancy in the ovary, usually intrafollicular; after inflammatory or endometriotic changes occasionally superficial; usually between 6-7 weeks, rupture with signs and symptoms of an acute abdomen*. pregnancy psychosis: see psychosis of

pregnancy. pregnancy signs: 1. certain pregnancy signs: a) fetal heart sounds; b) definite perception of fetal movements; c) definite palpation of fetal parts; d) identification of the embryo by ultrasound* diagnosis between 6-8 weeks; e) positive HCG* test in the maternal urine

pregnancy, extrauterine: pregnancy out-

side the uterus, intraabdominal pregnancy, graviditas extrauterina, ectopic pregnancy; development of the pregnancy outside the uterus. Localization: in the tube (tubal pregnancy*), ovary (ovarian pregnancy*), abdominal cavity (abdominal pregnancy*); most frequently in the tube. Early diagnosis of extrauterine pregnancy is difficult: suspicion if a period has been missed or bleeding occurred after a prolonged interval; unilateral cramping lower abdominal pain, not significantly enlarged uterus, with a positive (not obligatory!) pregnancy test, bleeding with passage of decidual tissue. A vague mass in the posterior fornix points to a hematocele. Staged diagnostic approach: ultrasound* diagnosis, culdocentesis and culdoscopy, laparoscopy* under general anesthesia, with the operating room ready for laparotomy. 194

Extrauterine pregnancy: Of 100 ectopic pregnancies, 99 are located in the tube, usually ampullary (1), less frequently isthmic (2), rarely intramural (interstitial) (3). Extremely rare are ovarian (4) and abdominal (5) pregnancies.

ematurity-dysmaturity prevention program

(see pregnancy tests); f) radiological recognition of fetal skeletal parts; 2. probable pregnancy signs: a) livid discoloration of the vaginal introitus; b) decreased smoothness and tissue density of the vagina; c) the vagina is wider and more distensible; d) corpus uteri is enlarged (see fundus height, Fig.); e) softening of the uterine corpus; f) painless contractions*; g) Piskacek's* sign; h) Hegar's* sign; i) Gauss'* sign; j) Pschyrembel's* sign; k) Osiander's* sign; 1) engorgement of breasts, formation of colostrum. 3. uncertain pregnancy signs: increase in the abdominal size, striae, pigmentation of face, linea alba, external genitalia (see chloasma); vomiting, pollakiuria, tendency to faint, increased irritability. pregnancy, termination of: induced abortion; purposeful termination of a pregnancy before embryo or fetus have reached extrauterine viability. Methods: 1. instrumental techniques: dilatation of the cervical canal, followed by suction curettage*, sharp curettage*, or a combination of both methods; menstrual* regulation. 2. pharmacological methods: for the initiation of labor with spontaneous expulsion of the pregnancy, usually result in cervical dilatation; mainly prostaglandins* (depending on the gestational age, intravaginal, intracervical, extraovular, or intraamniotic application); multiple complications (retained products, uterine lacerations, endometritis, sterility; associated with mortality); 3. surgical procedures: similar to cesarean* section (sectio* parva abdominalis); rarely used, e.g. for pregnancy after 16 weeks and indication for sterilization or hysterectomy (e.g. myoma). The use of the individual technique depends mainly on the gestational age and the age of the pregnant woman. pregnancy tests: immunological procedures for the diagnosis of a pregnancy (antigen-antibody reactions). Reliability > 95%. 1. hemagglutination inhibition test; principle: HCG contained in the urine of pregnant women is bound by anti-HCG (contained in an antiserum obtained by sensitising rabbits to human HCG). Subsequently therefore no antigen-antibody reaction takes place, when HCG-charged sheep erythrocytes are added; they fall to the bottom of the tube and form a sharply demarcated dark ring (positive result, at the earliest c. 10-14 days elfter the missed period). When HCG-free urine is examined, on the other hand, the anti-HCG still present in the first test sample reacts with the subsequently added erythrocytes, they remain in suspension (result negative). 2. inhibition of latex agglutination test; based on the same principle, but instead of erythrocytes HCG-charged latex particles are used. If no reaction takes place between these and anti-HCG (urine of pregnant women containing HCG), then the test sample remains cloudy (positive); with HCG-free urine the anti-HCG still present reacts with the latex particles, a visible granulated agglutination develops on the slide (negative). 3. radioimmunological demonstration of ß-HCG (already before missed period).

pregnancy, tubal: most important type of extrauterine pregnancy*; the most frequently occurring implantation* of the fertilized ovum in the ampulla of the tube, results elfter a few weeks in tubal abortion (so-called internal rupture of the gestational sac); expulsion of the pregnancy into the abdominal cavity (hematocele peritubal and in the Douglas'* pouch, slight vaginal bleeding); implantation in the isthmic or intramural part (interstitial pregnancy) results in rupture of the tube (so-called external rupture of the gestation sac), with severe (occasionally life-threatening) hemorrhage intraperitoneally, due to proteolytic weakening of the wall of the tube with erosion

of branches of the ovarian and uterine arteries. Signs and symptoms: sudden abdominal pain (peritoneal irritation), hemorrhagic shock, acute abdomen. Therapy: laparotomy, usually salpingectomy. pregnanediol: 3a,20a-dihydroxy-5ß-pregnane; C 2 iH 3e 0 2 ; metabolite and main excretory product of progesterone*, develops through reduction; pregnanediol is biologically largely inactive and can also be demonstrated in the urine of men. Its determination is chiefly used for the demonstration of ovulatory (biphasic) cycles and to monitor treatment for sterility.

pregnanediol excretion during pregnan-

cy: determination of the amount of pregnanediol* excreted daily in the urine of a pregnant woman; considered to be an (indirect) biochemical parameter of placental function, since pregnanediol is the main excretion product (15-30%) of progesterone*, and the fetus is not involved in the synthesis of progesterone (therefore not suitable for detecting fetal distress states!). A decrease in early pregnancy points to the development of a miscarriage; cf. unit, feto-placental. pregnenolone: 3-hydroxypregn-5-en-20one; C 2 iH 32 0 2 ; molecular weight 316.47; pregnenolone is a common intermediate product in the biosynthesis of all steroid* hormones. premalignancies: see precancer, carcinoma in situ. premature: before maturity, prematurity-dysmaturity

prevention

program: abbr. p.d.p. program; score for the identification and intensive surveillance of the pregnant women at risk for preterm delivery; the purpose of this program is to decrease the 195

premenarche

frequency of premature deliveries* and small-for-dates infants* by early diagnosis (risk screening at the time of prenatal care), and outpatient and inpatient intensive care of the pregnant women at risk. Cf. pregnancy, high-risk. premenarche: developmental phase of puberty* before the onset of menarche* in girls, characterized by the effect of ovarian estrogens and the development of secondary sexual* characteristics. The frequently generous amount of vaginal discharge may lead to the assumption that these girls have an abnormal discharge. premenopause: phase of climacteric* before menopause. premenstrual

syndrome:

abbr.

presentation, anomalies of: i n c l u d e d a r e :

high longitudinal position*, parietal bone presentation (see asynclitism), deep transverse arrest*, occipital presentation*, shoulder* dystocia. Cf. position, fetal. presentation, brow: see brow presentation, cephalic:

the

obstetrical

presentation in which parts of the fetal head form the presenting part, e.g. brow* presentation, occipital presentation*, face* presentation. Cf. position, fetal. presentation, compound: i n l o n g i t u d i n a l

lie prolapse of one or two extremities of the fetus alongside the presenting part at the beginning of labor; in transverse lie* prolapse of extremity as presenting part in the pelvis; cf. position, fetal. 196

presentation,

position,

occipital: o b s t e t r i c a l

pre-

sentation where the head of the fetus is acutely flexed and the occiput presents; usually the occiput is directed anteriorly (occipito-anterior or normal presentation) or posteriorly (occipito-posterior, see Fig.). Cf. position, fetal.

PMS;

characteristic physical and psychological changes of individually, variable intensity which start approximately 7 to 10 days before menstruation*, with disappearance at its onset Symptoms: irritability, emotional instability (also uncontrolled emotional reactions), moodiness, depression, painful tension and increase in the size of the breasts, bloating and indigestion, headache, back ache, skin changes and hot flushes, weight gain and swelling of the joints. Etiology: unknown; psychodynamic and endocrine causes are suspected. prenatal: before birth; cf. prepartal. pre-ovulatory phase: the last 3 to 4 days before ovulation; very important phase in the menstrual* cycle, since only during this time the characteristic changes in the cervical mucus take place, which permit migration of the sperm through the cervical canal; cf. fertile days. prepartal: also antepartum; before delivery; cf. prenatal. prepubertal: before puberty*, prepuberty: the time before the development of pubic hair (pubarche); cf. puberty, prepuce: foreskin of penis or clitoris*, preputium clitoridis: prepuce of the clitoris*; joining of the respective external anterior folds of the small labia (labia* minora pudendi) above the clitoris. presentation: (obst.) relation between the presenting part of the fetus and birth canal as a result of fetal attitude and position; see position, fetal.

presentation,

presentation, longitudinal: s e e

fetal.

Occipital presentation: First or left (above) and second or right occipito-posterior presentation (below)

presenting part: lowest point of the presenting fetal part in the pelvic axis during delivery. Posterior fontanel is the presenting part in occipito-anterior positions. pressure, fundal: maneuver to complement of inadequate maternal pushing for the delivery of the fetal head, shoulders, or in breech presentation; at the time of contraction the assistant pushes the upper pole of the fetus into the pelvis. PRH: abbr. for prolactin releasing hormone, prolactoliberin; postulated hypothalamic hormone, promoting the secretion of prolactin* from the anterior pituitary lobe; cf. releasing hormones. Primigravida: woman who is pregnant for the first time (is defined as a nullipara* during pregnancy); cf. history, obstetrical. primipara: woman who is giving birth for the first time; cf. history, obstetrical, procidentia of uterus: s e e p r o l a p s e ,

progesterone (INN-Ε): progesteronum (INN-L), 4-pregnen-3,20-dione (IUPAC); CASNo. 57-83-0; ΟϋΗ30Ο2; molecular weight 314.51; physiological corpus luteum hormone, most important natural gestagen, is mostly produced in the corpus* luteum and placenta (but also in the adrenals); important precursor of the steroid* hormones, biological half-life c. 20 min. The main metabolite pregnanediol is excreted renally as glucuronide (formerly determined to diagnose a pregnancy or an anovulatory cycle). In interaction with and after pre-

prolapse, anal

vious estrogen* priming of the reproductive organs, progesterone is involved in the regulation of almost all female reproductive functions; it determines the characteristics of the luteal phase in the menstrual* cycle, prepares the body for pregnancy, creates conditions which are important for conception and nidation, has a pregnancy-maintaining action, and induces, among others, typical changes in the composition and characteristics of the cervical secretion and the vaginal epithelium. Progesterone has a thermogenetic effect independent of the estrogens (increase in body temperature by c. 0.4-0.6 °C; see body temperature, basal). Normal values (in pg/ml serum; reference standard: mass spectrometry): in women in the follicular maturation phase of the menstrual cycle 1500, in the luteal phase 3000-20,000, in pregnancy 15,000-50,000 (1st trimester) and 50,000-200,000 (3rd trimester); in men below 1000. CH 3

XJ CH 3

r

f

i

:= o

J Progesterone progesterone

dermatitis,

progesterone

effect:

autoimmune:

see autoimmune progesterone dermatitis. dilatation

of

smooth-muscled hollow organs (e.g. uterus, bowel, ureters) in pregnancy due to progesterone effect. progesterone test: see gestagen test, prolactin: previously also called luteotropic hormone (LTH); single-chain lactotropic protein hormone of 198 aminoacids, is produced in acidophilic cells of the anterior pituitary lobe (APL); molecular weight about 23,000, but higher molecular weight forms also occur in the hypophysis and the serum (so-called big prolactin and big big prolactin), the physiological significance of which is not yet known. Prolactin stimulates breast growth and, (in the presence of Cortisol) after previous estrogen- and progesterone-priming of the breasts, initiates the production of milk (lactation*). The excretion of prolactin from the APL is inhibited by PIH, promoted by TRH (and possible PRH), mechanical stimulation of the nipple (suckling stimulus), and also through stress, surgical procedures, and hunger. The serum prolactin is determined radioimmunologically; cf. hyperprolactinemia, prolactinoma. prolactin-inhibiting factor: see P I H .

prolactin-inhibitors: (pharmac.) substances which inhibit both physiol. (postpartum) lactation and also pathol. galactorrhea; dopamine acts as a physiological prolactin inhibitor via specific receptors in the prolactin-secreting cells of the hypophysis*. The dopa-

mine agonists bromocriptine* and lisuride* probably also have a hypothalamic site of action. Therapeutic use: for prolactin-induced fertility disorders, premenstrual syndrome, mastitis, and for the primary and secondary inhibition of lactation; in microprolactinoma, acromegaly, and Parkinson's syndrome. prolactinoma: rare macro- or microadenoma of the anterior lobe of the hypophysis, with autonomous secretion of prolactin* (hyperprolactinemia*) and corresponding signs and symptoms: mainly amenorrhea*, galactorrhea*, interference with libido and sexual potency; due to local displacement it may cause (partial) hypopituitarism*, visual defects (chiasma optici), and headache. Diagnosis: computed tomography of sella turcica, serum prolactin determination (above 200 μg/l diagnostic). Therapy: prolactin*-inhibitors, surgery (transphenoidal or frontal), radiation therapy. prolapse (Lat. prolabi to fall before): significant descent of the uterus (and vagina); the genital organs may descend partly or completely beyond the vulva. 1. partial prolapse: only part of the uterus (e.g. the cervix with or without the vagina) has descended beyond the vulva. 2. complete prolapse: vagina is completely everted and has descended beyond the vulva. Descent of the uterus causes shortening of the vagina, with resulting prolapse of the anterior and posterior vaginal wall: descensus vaginae anterior et posterior. Since the vaginal wall is firmly attached by the perivesicular tissue to the bladder wall, any descent of the anterior vaginal wall will result in a cystocele (descent of the bladder floor). Descent of the posterior vaginal wall will result in a rectocele (descent of the anterior wall of the rectum) which is less pronounced, since there is less connective tissue attachment to the rectum. Frequently seen in association with the descent and prolapse is elongation of the cervix. Etiology: pelvic floor weakness (e.g. due to deliveries), weakening of the ligaments, pendulous abdomen. Signs and symptoms: pelvic fullness and pressure, back pain, urinary symptoms (relative urinary incontinence, socalled stress incontinence*), pollakiuria (severe descent may frequently be associated with obstructive signs, including retention), frequently cystitis, vaginal discharge*, occasionally decubitus ulcers with the potential for significant hemorrhage. Therapy: usually surgical-vaginal repair (see colporrhaphy), occasionally vaginal hysterectomy; pessary* treatment if surgery is contraindicated. Cf. descensus uteri. A decubitus ulcer can develop into a malignant tumor (carcinoma)! At the slightest suspicion, biopsy!

prolapse, anal: prolapse of the anal mucosa (radial folds), usually associated with hemorrhoids* (congestion in patients with congenital deficiency of the connective tissue). Type I (false anal prolapse): prolapse of redundant 197

prolapse, rectal

mucosa through the anus. Type II (incomplete anal prolapse): prolapse of the intussusception of all layers of the rectum. Type III (true or complete anal prolapse): sliding hernia of the peritoneum of Douglas' pouch, congenital (children) or acquired (adults). Therapy: depends on individual findings (conservative, surgical, or injection of sclerosing solutions).

chidonic acid, which is released from membrane lipids through phospholipases. To date at least 5 groups with numerous sub-groups have become known; physiologically important PG are PGE^ PGF 2a) and PGI 2 (prostacyclin). Actions: many different, sometimes opposite, effects, e.g. on the action of the catecholamines, smooth muscle tone, and the cardiovascular system (hypotensive and hypertensive effects), inhibition of thrombocyte aggregation, reduction of gastric juice secretion, increase in the synthesis and release of certain tissue hormones, and the hormone secretion of various endocrine organs (thyroid gland, parathyroid gland, adrenal cortex, ovary), cytoprotective effects. PG have a pathophysiological role in the development of fever, pain, and inflammatory processes. The synthesis of .COOH

arachidonic acid

prolapse, rectal: see prolapse, anal, prolapse, vaginal: prolapsus vaginae, with descent of the vagina beyond the vulva; usually associated with prolapse of the bladder (cystocele) or rectum (rectocele; see prolapse). Descent of the vaginal walls to the level of the vulva is called vaginal descent; see descensus uteri. proliferation dose: syn. build-up dose; total dose of estrogens* required for full proliferation of the resting endometrium* to the extent that secretory transformation through gestagens* is then possible; see transformation dose. proliferative phase: also follicular maturation phase; see menstrual cycle. promiscuity (Lat. promiscuus mixed): sexual behavior characterized by frequent change of partners; cf. hypersexuality. promontory: the projection of the spine jutting ventrally into the pelvis at the lumbosacral transition; comes about by the distinct angle of the lumbar vertebrae against the sacrum* (angulus lumbosacralis); both the vertex of this angle and the point of the os sacrum projecting the furthest ventrally, usually, however, the ventral edge of the intervertebral disc connecting the 5th lumbal vertebra to the sacrum is called promontory. Cf. measurements, pelvic. prone position: for infants the prone position offers several advantages over the supine position for the development of the child: stimulation of static functions, prevention of postural anomalies. prostaglandins: abbr. PG; collective term for numerous natural (or partly synthetic) hormone-like substances (tissue hormones and mediators), which vary slightly in their structure and are chemical derivatives of prostanoic acid; they were first demonstrated in the seminal fluid and the gonads, later in almost all organs. One of the precursors is ara198

I cyclooxygenase

ο— I

ο

OOH

PG G,

Ο—-/

COOH

I

ο OH

PG H,

'thromboxane synthetase

^h thromboxane A 2

COOH

PG F „ Prostaglandins: Diagram of the biosynthesis

pseudoprecocity

prostaglandins is promoted by many physiol. substances, which in turn are sometimes released in increased amounts through PG (e.g. tissue kinins). The inhibitors include the nonsteroidal antiinflammatory agents. Therapeutic use (and possible uses): in bronchial asthma, gastric ulcers (inhibition of secretion and mucosal protection), circulatory diseases; (obst) for the induction of birth, as abortifacient, in atony of the uterus (atonic postpartum hemorrhages). Side effects: nausea, coliclike pain, diarrhea.

Prostaglandins: Prostanoic acid

proteinuria of pregnancy: renal impairment due to decreased circulation, associated with albumin and casts in the urine; usually seen in the second half of pregnancy. Cf. pre-eclampsia. pruritic urticarial papules and plaques in

pregnancy: abbr. PUPPP* syndrome. pruritus ani (Lat. prurire to itch): itching in the anal area; etiology: hemorrhoids, anal eczema, fungal infections, anal prolapse, anitis, proctitis, anal fistula, food allergies, enterobiasis, contact allergy (e.g. soaps). pruritus of pregnancy: generalized pruritus, occurring in the last trimester, assumed to be due to cholestasis and individual predisposition, may be associated with cholestatic jaundice; disappears shortly after delivery; in the second trimester, pruritus may also be caused by papular* urticaria or (in the third trimester) by the PUPPP* syndrome. pruritus vulvae: usually severe pruritus in the area of the vulva*, especially at night, due to capillary dilatation (increased warmth); primary (essential, idiopathic) pruritus vulvae, probably psychosomatically based, or secondary as a symptom of diabetes mellitus, estrogen deficiency (climacteric, postmenopause), kraurosis* vulvae, leukoplakia* vulvae, vaginal infection with discharge, enterobiasis, parasitosis (pubic lice, scabies), inadequate or excessive hygiene. Pschyrembel's sign (Willibald Pschyrembel, gynecologist, obstetrician, and medical lexicographer, Berlin, 1901-1987): sign of pregnancy* demonstrable in the 2nd-4th month of pregnancy; a relatively firm core surrounded by a softer layer is palpated in the cervix of the pregnant uterus. pseudocyesis: syn. pseudopregnancy*. pseudohermaphroditism: presence of gonads of one sex and the genitals and secondary sexual characteristics of the other sex, with concurrence of gonadal and chromosomal sex. In female pseudohermaphroditism (karyotype 46.XX; ovaries) the outward appear-

soft f i r m s o f t

ance is primarily masculine, e.g. in congenital or acquired adrenogenital syndromes, or effects of androgens during pregnancy (maternal hormone treatment, or hormone-producing tumor); in male pseudohermaphroditism (karyotype 46,XY; testes) external genitals and secondary sexual characteristics are primarily female, among others in testicular feminization, Reifenstein's syndrome, Swyer's syndrome, and congenital adrenogenital syndromes; see intersexuality (Table). pseudo-Klinefelter's

syndrome

(Gr.

pseudes false): development of hypergonadotropic hypogonadism* due to sclerosing changes in the testes, usually occurring in the third or fourth decade, associated with loss of libido and sexual potency, as well as aspermia. The cause of the tubal sclerosis with loss of androgen-producing cells is unknown; the clinical manifestation is similar to Klinefflier's* syndrome. The karyotype of the patients is normal (46.XY). pseudomamma: the presence of an accessory breast with nipple and areola; however, fat tissue instead of glandular parenchyma; congenital anomaly. pseudo-Meigs'

syndrome:

see

Meigs'

syndrome. Pseudomenstruation: menstruation-like bleeding, caused by estrogen withdrawal or relative estrogen deficiency in an anovulatory* cycle; cf. bleeding, withdrawal. pseudomucin: syn. metalbumin, paralbumin; mucoid which is present in mucinous cystadenoma* or cystadenocarcinoma*, does not precipitate with acetic acid. pseudomyxoma peritonei: accumulation

of mucinous material (pseudomucin*) in the peritoneal cavity with abdominal distension and ultimately interference with the gastrointestinal tract, usually elfter rupture of a mucinous cystadenoma* or cystadenocarcinoma* of the ovary with subsequent peritoneal implantation of mucus-producing tumor cells, see Fig., next page; frequently lethal outcome due to progressive cachexia after prolonged course (even if the tumor is benign and repeated surgical procedures for the evacuation of the mucinous material from the abdominal cavity have been performed). pseudoprecocity: iso- or heterosexual premature development, also called peripheral 199

pseudopregnancy

Pseudomyxoma peritonei: The abdominal cavity has been opened and is completely filled with large amounts of mucinous material and proliferating cysts from ovarian cystadenoma pseudomucinosum.

type of precocious puberty*. Etiology: not based in the hypophysis but in other hormone-producing glands (gonads, adrenal cortex). In contrast to true precocious puberty, neither ovulation nor spermatogenesis occurs; cf. granulosa*-cell tumor, adrenogenital syndromes. pseudopregnancy: also pseudocyesis; 1. imaginary pregnancy: graviditas imaginata, (Fr.) grossesse nerveuse; psychogenic wishfulfilment neurosis with signs resembling those of pregnancy (absence of menstruation, swelling of the abdomen); 2. so-called artificial pregnancy; see pseudopregnancy treatment. pseudopregnancy treatment: a method of hormone therapy with the administration of estrogen-gestagen combinations in high doses for 8-12 weeks. Indications: genital hypoplasia, Sheehan's syndrome (see hypopituitarism), (hypothalamic) amenorrhea* (induction of spontaneous cycles through a reactive rebound* effect), endometriosis* (increasing dosage to suppress menstruation bleeding). Cf. pseudopregnancy. psychosis of pregnancy: syn. gestational psychosis; a psychosis which occurs during pregnancy, frequently as endogenous depression*. Occurrence: rare; psychological complications occur more frequently postpartum (cf. psychosis, postpartum), since pregnancy, especially the second trimester, appears to have a stabilizing effect. Psychosis of pregnancy may have a prolonged course with questionable prognosis. Therapy: depending on the clinical picture neuroleptics and/or antidepressive treatment taking into account contraindications (transplacental passage!). psychosis, post abortion: psychological illness Elfter abortion; in the narrowest sense a symptomatic psychosis; in the widest sense depressions and other disturbances are included; cf. depression, psychogenic. psychosis, postpartum: syn. puerperal psychosis; nosologically not uniformly used and not clearly defined, clinically however an indispensable term. Incidence: 1-2 cases per thousand deliveries, onset usually in the first 200

two weeks, rarely 6 to 12 weeks post partum. Signs and symptoms: frequently rapid change of the symptomatology: sudden onset with a manic or depressive state, pronounced unrest, violent agitation, and frequently also an otherwise rarely seen state of confusion (amentia); sleep disturbances, anxiety, perplexed astonishment, mistaking of people, disorientation, acoustic and optic hallucinations, and delusions about the present living conditions; deterioration in the evening. Duration 2 to 3 weeks, occasionally months (especially with depressive syndromes). Etiology: probably a combination of disposition, endocrine changes, and psychodynamic factors. Therapy: psychotropic drugs after discontinuation of lactation (mild or strong neuroleptic compounds, occasionally short-term tranquilizer treatment), psycho- and social therapy. Protection from external stimulation. Combined hospitalization of mother and child is helpful to prevent secondary neurosis due to the psychosis. Prognosis: good on short-term basis. Relapses are rare in the puerperium, although prophylactic psychiatric support is recommended. Relapses independent of puerperium are seen more frequently (affective psychosis or schizoaffective psychosis). pubarche (Lat. pubes of marriageable age; Gr. arche beginning): beginning of the growth of the pubic hair (androgen effect) in puberty*. puberty (Lat. pubertas sexual maturity): developmental phase of a young person from the beginning of the development of secondary sexual characteristics (see also thelarche, pubarche, menarche) to completion of sexual maturity. Sexual maturation is associated with Puberty

Temporal stages of the physical development of girls in puberty Age

Signs

< 8 yrs. infantile state 1 0 - 1 1 yrs. thelarche growth spurt maturation of vaginal mucosa 11 yrs. pubarche 1st sesamoid bone 1 1 - 1 2 yrs. maximum growth spurt 13 yrs. menarche irregular anovulatory cycles axillary hair 1 4 - 1 5 yrs. regular ovulatory cycles pregnancy possible 1 6 - 17 yrs. epiphysial closure completion of growth

Tanner Stages Β 1, Ρ 1 Β 2, Ρ 1

Β 2, Ρ 2 Β 3, Ρ 3 Β 4, Ρ 4

Β 5, Ρ 5

punctation

profound physical, psychological, and social changes. Temporal development in 2 phases: 1st phase (in Europe) in girls between IOV2 and I3V2 years, in boys between 12 and 15 years; 2nd phase in girls between I3V2 and 15V2 years, in boys between 15 and 17 years. In girls the culmination of puberty is menarche. The physical change is characterized by the development of secondary sexual* characteristics with a growth spurt, which occurs in girls in the 12th, and in boys in the 14th year. Frequently acne* vulgaris is present The psychological development is characterized by feelings of insecurity which may have suicidal contents. Environmental aspects play a critical role in the psychological development Cf. Tanner stages, life stages. puberty, delayed: delayed puberty (2-3 years after age-related average), of questionable medical significance. Etiology: 1. idiopathic delay in maturation; 2. malnutrition, general illnesses; 3. ovarian causes (hypogonadism, gonadal dysgenesis, ovarian hypoplasia, tumors, cysts, torsion); 4. causes related to the CNS (hypothalamic tumor, inflammation, trauma). Compared to the age norm, the bone age may be delayed by 2V2 or more years, due to the lack of influence of sexual hormones on bone maturation. Diagnosis: if in girls at the end of the fourteenth year there is no breast and genital development nor axillary hair and pathological conditions, delayed puberty can be observed on a short-term basis or treated cyclically with an estrogen/progesterone combination. puberty, precocious: premature sexual development with evidence of sexual maturation, in girls before age eight in boys before age ten. Central type (pubertas praecox vera hypothalamica) with isosexual precocious development due to organic processes in the diencephalon (pinealoma) or idiopathic (hypothalamic dysregulation); conception is possible. The peripheral type is now called pseudoprecocity. In addition to counselling and education, limited success has been achieved with the use of progesterone or the anti-androgenic drug cyproterone acetate in order to attempt pharmacological blocking of premature sexual development Cf. McCune-Albright syndrome. pubes: 1. pubic hair; 2. the genital area, pubic angle: width of the pubic angle (angle of the inferior pubic rami, usually approximately 90°); of importance in the obstetrical evaluation of the pelvis. Narrow pubic angle (generalized narrow pelvis) indicates a narrowing of the pelvic outlet. Cf. pelvis, narrow, pubic arch: see arcus pubis, pubic area: regio pubica; region of the external genitalia. pubic bone: os* pubis,

pubic crest: see crista pubica, pubic hair: hair covering the pubic mount (mons pubis, mons veneris). pubic ligament, superior: see ligamentum

pubicum superius. pubic mount: mons pubis, in females mons veneris; the hairy region above the anterior

Estimating the pubic angle

commissure of the large labia or penis. pubiotomy: syn. hebetomy, hebotomy; cutting of the pubic bone next to the symphysis pubis; a now obsolete technique in prolonged labor. pubovesical

pubovesicale.

ligament:

see

ligamentum

pudendal arteries, external: see arteriae

pudendae externae. pudendal canal: duplication of the fascia obturatoria in the lateral wall of the fossa* ischiorectalis; contains the vasa pudenda interna and the nervus pudendus. Cf. fascia pelvis. pudendal nerve: see nervus pudendus, pudendum femininum: female vulva; the external female genitalia; see genital organs. pudendus: belonging to the pubic region, pertaining to the pubic region. puerperal fever: see fever, puerperal. Puerperium (Lat puerpera women in childbed): lying in; period from the delivery to the complete reversal of the changes of pregnancy and birth in the mother (involution* phase); duration: 6 to 8 weeks (early puerperium: first 7 days). Initiation of lactation, initiation of nursing*. Psychological reactions: approximately 50% of puerpera notice the socalled postpartum blues; duration: several hours to a few days. Symptoms: loss of energy, inability to concentrate, oversensitivity, depressive mood with tendency towards weeping. Etiology: hormonal changes, specifically rapid decrease in estrogens and progesterone. Therapy: supportive psychotherapy. pulmonary failure, congestive: alveolar

perfusion deficiency in newborns due to atelectasis and vascular congestion (relatively large blood volume). The resulting dyspnea is usually rapidly resolved, but may, however, result in respiratory distress (transient tachypnea of the newborn "wet" lung), if the vascular permeability is increased, and excessive transudation is present punch biopsy: removal of tissue from the cervix with an appropriate biopsy forceps (see Fig, next page) from areas macroscopically or colposcopically suspicious for cancer to obtain a specific histological diagnosis; indicated if regular cytological monitoring is not possible. punctation: (gyn.) suspicious colposcopic finding; irregular, iodine-negative areas on the 201

PUPPP syndrome

tive or other predisposing factor. Pyelonephritis without underlying factors is called primary, while secondary pyelonephritis is due to obstruction or other local factors. Acute pyeloPunch biopsy: Biopsy forceps

cervix, with fine nodular surface and multiple capillaries, visible as red dots; may represent so-called leukoplakia punctuation (connective tissue base after removal of the superficial layers), or occur independent of leukoplakia*. Cf. colposcopy. PUPPP syndrome: abbr. for pruritic urticarial papules and plaques of pregnancy; dermatological disease with itching rash of unknown etiology, occurring in the third trimester. pushing: a voluntary increase in intraabdominal pressure in order to support contractions*, starting with the second stage; pushing serves to overcome the external soft-tissue resistance by further increasing abdominal pressure several times that of the intrauterine pressure alone (approximately 200 mmHg); see also contractions, second stage. pyelitis (Gr. pyelos pelvis): pyelonephritis; bacterial infection of the renal pelvis. Since pyelitis alone without involvement of the renal parenchyma is unlikely to occur, the term pyelonephritis* or interstitial nephritis is preferred. Types: pyelitis acuta, pyelitis chronica, pregnancy pyelitis (see pyelonephritis gravidarum) due to hypotonia of ureter and renal pelvis, or compression of the ureter, reflux pyelitis due to obstruction of the urinary tract. pyelonephritis (Gr. nephros kidney): special type of interstitial nephritis; bacterial infection of the renal interstitial tissue and calyceal system (pyelitis) with possible extension into the tubuli, vascular system, and glomeruPyelonephritis is the most frequent renal disease. li. Organisms (according to frequency): £. coli (25-60%), enterococci (5-30%), Proteus (10 to 20%), staphylococci (3-15%), Pseudomonas (1-5%), Klebsiella (1-5%). Causes: 1. mechanical obstructive factors: obstruction of the urinary tract or anomalies; 2. hematogenous (descending) infection during or elfter enteritis, tonsillitis, appendicitis, cholecystitis, prostatitis, adnexitis; 3. predisposing factors: pregnancy, metabolic diseases (diabetes mellitus, gout, phenacetin abuse) or functional disturbances (vesico-ureteral reflux, paraplegia). Pyelonephritis occurs commonly in infants; it is thought to be due to (ascending) fecal infection during the diaper period. Pyelonephritis occurs twice as frequently in women than in men, usually during pregnancy (pyelonephritis* gravidarum). In boys and men pyelonephritis is usually associated with an obstruc202

Notable frequency of pyelonephritis in children up to 3 years (girls 3 times as frequent as boys). nephritis is characterized by fever (sometimes with chills) and pain in one or both costovertebral angles. The pain radiates along the course of the ureter into the pubic area. Frequently malaise, thirst, nausea, and vomiting may be present. Chronic pyelonephritis is often associated with few or no symptoms (nonspecific generalized symptoms: malaise, loss of appetite, headache). Fever is rare, and, if present (in approximately 25% of cases), subfebrile. Occasionally, pallor, thirst, and polyuria are seen. Diagnosis: 1. urine: a) urinalysis: examination for protein (proteinuria), sugar (glycosuria), nitrite (bacteriuria), erythrocytes (hematuria), and pH measurement; specific gravity; b) confirmation of significant bacteriuria* and microscopic examination of the urine: sediment for leukocytes, erythrocytes, epithelial cells, casts; c) extended urinalysis: quantitative assessment of leukocytes and erythrocytes, epithelial cells, casts. Bacteriological determination of organisms, number of colonies, and sensitivity. 2. routine laboratory examination: sedimentation rate, complete blood count, BUN, creatinine, uric acid, electrolytes, electrophoresis, transaminases, acid/base status, and serum glucose. 3. ultrasound examination: diagnosis of a urinary tract obstruction (hydronephrosis, urinary retention), evaluation of the kidneys for anomalies. 4. radiologiThe following radiological signs are an indication of the involvement of the renal parenchyma in an infection of the upper urinary tract: 1. abnormal size of the organ and its collecting system; 2. changes in the calyces and papillae; 3. disintegration of the pyelorenal barrier with increased pyelorenal reflux; 4. chronic pyelonephritis and pyelonephritic atrophic kidney: an angiogram will indicate the reduction of renal parenchyma and the decreased perfusion of the organ. cal examination: after resolution of the acute stage an I.V. pyelogram should be performed to exclude morphological anomalies: deformity of the calyceal system, parenchymal atrophy, obstructions, or abnormalities. Only the diagnosis of interstitial nephritis can be made exclusively radiologically. If the I.V. pyelogram indicates a suspicion of nephritic changes, a cystogram is performed to rule out

pyuria the possibility of vesico-ureteric reflux. 5. cystoscopy is indicated, if there is significant involvement of the lower urinary tract; in girls and women a gynecological examination may become necessary, β. if functional impairment of the kidneys is suspected, detailed evaluation of the renal function is necessary. The radiological examination can never provide a disease-specific diagnosis. Therapy: in acute pyelonephritis bedrest until afebrile, large amount of fluids, specific antibacterial chemotherapy, preferably after determination of sensitivity (during pregnancy only drugs which do not cause embryonic or fetal anomalies). Chronic pyelonephritis is associated with predisposing factors (obstructions, anomalies, reflux, etc.) which must be treated surgically; the antibiotic treatment must be specific, preferably alternating between short-term therapy with high antibiotic doses and well-tolerated longterm treatment (intermittent bolus therapy). Prognosis: primary acute pyelonephritis has an excellent prognosis if diagnosed early and treated aggressively. Pyelonephritis (especially secondary) tends to recur. Its (poorer) prognosis is determined mainly by the intensity of medical surveillance and treatment. Patients with pyelonephritis which is recognized only late (chronic) tend to develop compensated and ultimately decompensated renal insufficiency.

pyelonephritis gravidarum: also pregnancy pyelonephritis; a frequent complication in the second part of pregnancy. Etiology: exacerbation of asymptomatic bacteriuria of pregnancy* due to: 1. mechanical compression of the urinary tract due to the enlarging uterus; 2. progesterone-related atony of the ureters with decreased peristalsis; 3. compression of the ureter by the ovarian venous plexus; 4. more rapid growth of bacteria in the urine of pregnant women due to change in pH value and increased content of aminoacids, creatinine, glucose, lactose. pyknotic index: see karyopyknotic index, pyometra (Gr. pyon pus): pus collection in the uterine cavity; among others, found in patients with endometrial or cervical carcinoma, after intracervical radiation therapy, after endometritis, colpitis senilis, and with tuberculosis of the endometrium. Therapy: dilatation of the cervical canal and drainage; cf. hematometra. pyosalpinx: see salpingitis, pyovarium: suppuration of the ovary; see abscess, ovarian; oophoritis. pyuria: presence of pus in the urine, with macroscopic clouding, seen in purulent inflammatory conditions of the urogenital tract or in its vicinity. Two-glass test: initial pyuria with initially cloudy and later much clearer urinary specimen indicates urethral origins; terminal pyuria with initially clear and later cloudy specimen points in males to prostate and seminal vesicles; pyuria throughout indicates infection of bladder or ureter and kidney. Cf. leukocyturia, bacteriuria, pyelonephritis.

203

ο quadrant resection: so-called Milanese breast operation; modified radical operation after Veronesi for the surgical treatment of small breast* carcinoma. Technique: tylectomy* extended at least to one quadrant including resection of the corresponding nipple segment with axillary lymphadenectomy and subsequent radiation treatment of the remaining breast tissue. Advantage compared to

204

mastectomy* is the conservation of the breast; disadvantage: risk of local recurrence in multicentric carcinoma. quadruplets: see pregnancy, multiple, quinestrol (INN): quinestrolum (INN-L), 3-cyclopentyloxy-17a-ethinyl-estra-l,3,5( 10)-trien-17ß-ol (IUPAC); CAS No. 152-43-2; CMHJJA; molecular weight 364.57; synthetic estrogen. Cf. estrogens.

radiation bladder (Lat. radius ray): functional and morphological sequelae at the urinary bladder after percutaneous or intracavitary radiation* therapy of the true pelvis with cell damage, circulatory disorders of the tissues, and necroses. A distinction is drawn between: 1. early radiation reactions: symptoms of irritation of varying severity, esp. as a result of cellular damage to the mucous membrane; 2. late radiation reactions: atrophy of the mucous membrane, development of telangiectasias, chronic ulcers of the mucous membrane. 3. chronic radiation damage: change in the muscular components of the bladder wall, development of so-called contracted bladder; sometimes with fistula formation (bladder fistulae, urogenital fistulae). radiation castration: (radiol.) sterilization by means of X-rays; elimination of the function of the gonads* through irradiation with X-rays; now obsolete! Cf. amenorrhea, therapeutic. radiation damage, genetic: changes in t h e

genetic material (chromosomes* or DNA) induced by ionizing radiation; may manifest as mutagenic or carcinogenic effects and, like all toxic effects, are strictly dose-dependent. A summation of high (carcinogenic) radiation doses over short periods of time must be considered as likely, the possibility of an additive effect of very low doses over very long periods of time cannot be scientifically assessed at the present time. radiation osteonecrosis: syn. osteoradio-

necrosis; bone necrosis which develops after external irradiation, dependent on the absorbed dose of the ionizing radiation, as a result of damage to the cellular elements of the bone tissue, and also to the connective tissue cells of the blood vessels which supply the bone; radiographic changes (demineralization, loosening of structures) can often not be recognized until after a period of months to years. The pathologically altered bone tissue is functionally inferior and less capable of taking static stress (spontaneous fractures!). Occurrence: known, e.g, in the region of the pelvis after gyn. irradiation for female genital carcinoma, possibly with subsequent fracture of the neck of the femur (relatively good healing tendency). radiation therapy: 1. in a narrower sense the use of ionizing radiation for the (curative or palliative) treatment of malignant (sometimes also benign) neoplasias, alone or combined with surgical or chemotherapeutic measures. Gamma- (also X-) radiation, protonneutron- (sometimes also pi meson-) radiation,

in certain regions also fast electrons and alpha-rays are used. The object of radiation therapy is to achieve maximal damage to the tumor tissue with, at the same time, maximal sparing of the surrounding healthy tissue. For this either the tumor tissue must display greater radiation sensitivity than healthy tissue (as a rule, this is the case especially with rapidly growing undifferentiated tumors), or else the dose of radiation in the tumor must be selectively increased by selecting the most suitable irradiation geometry: e.g. internal or external irradiation, the use of radiation of varying range, the use of fixed or movable radiation sources. (With the so-called pendulum irradiation, for example, the beams emitted from a movable radiation source meet in the tumor region, whilst the surrounding tissue is spared.) Finally, greater damage to the tumor tissue can be achieved by the selection of the dose distribution over time (e.g. fractionation); cf. teleradiation therapy, contact radiation. 2. in a wider sense any use of electromagnetic waves for therapeutic purposes (e.g. microwaves, infrared radiation, visible light). radiation therapy, intracavitary: irradia-

tion through radionuclides introduced into body cavities (e.g. uterus, peritoneum); cf. radium therapy, contact radiation. radical mastectomy: see Halsted's operation. radiological diagnosis, obstetric: in

a

narrower sense radiological pelvimetry; rarely used today during a pregnancy, because the true conjugate (see measurements, pelvic) can be determined by means of ultrasound diagnosis. Main indication: vaginal delivery with breech* presentation (exclusion of impediments to rotation of the head in the true pelvis). For overview of the radiation exposure of the embryo and fetus during radiodiagnostic measures: see Table, next page. radium therapy: radiation therapy with the use of radium-226 in the form of radium needles. These needles are brought into direct contact with the tumor tissue (contact* radiation), so that a high dose is reached in the lesion. Main indication for use: irradiation of tumors of the female genitals, often combined with percutaneous teleradiation* therapy. ramus dorsalis (Lat. ramus branch): posterior weaker branch of a very short spinal nerve (see nervi spinales); innervates skin of the back and the corresponding segmented musculature of the back; carries sensory, motor, and autonomic fibres, divides into r. medialis and r. lateralis. ramus ovaricus: *a. uterina; > along 205

ramus tubarius Obstetric radiological diagnosis Estimated mean dose to the embryo or fetus during radiodiagnostic measures in pregnancy Region of the mother's body exposed to diagnostic radiation

Dose to the embryo or fetus in mSv (mrem)

Skull Cervical vertebral column Upper/lower extremity Thoracic vertebral column Lumbar vertebral column Pelvis (survey) Hip joint Lungs Fluoroscopy Radiography Photofluorography Abdomen (survey) Upper gastrointestinal tract Fluoroscopy Radiography Total Intestinal tract (barium contrast visualization) Fluoroscopy Radiography Total Gall bladder Pyelogram (I.V. or retrograde) Pregnancy radiography

0.04 0.02

(4) (2)

0.01 0.09

(1) 0)

2.75

(275)

4.40 3.00

(440) (300)

0.70 0.08 0.08 2.90

(70) (8) (8) (290)

2.00 3.60 5.60

(200) (360) (560)

3.60 4.40 8.00 2.00 4.00

(360) (440) (800) (200) (400)

7.23

(723)

the lig. ovarii proprium to the ovarium; forms with the r. tubarius (*a. uterina) an anastomosis to the a. ovarica (*aorta abdominalis), termed the ovarian arcade. ramus tubarius: *a. uterina; — > in the mesosalpinx; anastomosis with the a. ovarica (*aorta abdominalis). ramus ventralis: anterior stronger branch of a spinal nerve (see nervi spinales); forms plexus in cervical and lumbosacral areas with neighboring rr. ventrales (plexus cervicalis, brachialis, lumbalis, sacralis), i.e. not the entire trunk of the spinal nerve is involved in forming these plexuses. In the thoracic area the rr. ventrales run without plexus formation as intercostal nerves. RDS: abbr. for respiratory distress syndrome; see respiratory distress, neonatal. readiness for birth: the readiness for birth, i.e. the outlook for the course and duration of labor and delivery is determined by a vaginal examination, assessing length, consistency, and position of the cervix, dilatation, station of the presenting part. The information may be quantified by scoring systems, e.g. the Bishop score (see cervix score). Read's method (Grantley Dick-Read, 206

gynecologist, London, 1890-1950): a technique to achieve a low-pain birth more or less successfully through systematic preparation of the pregnant woman consisting of a combination of information about the processes of birth and physical, respiratory, and relaxation exercises; cf. childbirth preparation. rebound effect: hormonal regulatory mechanism, also called inhibiting effect (inhibiting therapy). Example: through the administration of steroid hormones in a certain dosage for a fairly long period of time the secretion of the corresponding releasing* hormones from the anterior pituitary lobe can be inhibited as a result of negative feedback*; if the steroid hormones are suddenly discontinued, an excessive amount of the releasing hormones is then secreted, so that the target organs (gonads, adrenal cortex) may be stimulated to hormone synthesis greater than that before the hormone administration. receptors, hormonal: see hormone receptors. rectal plexus: see plexus rectalis inferior, rectocele: sacculation of the posterior vaginal wall just above the introitus vaginae as a result of weakness of the septum rectovaginale; often combined with a sacculation of the Douglas' pouch with herniation of intestinal loops (douglascele, enterocele). Cf. prolapse. rectoscopy: endoscopic examination of the rectum and possibly of the sigmoid colon (rectosigmoidoscopy) with the tubular rigid (or flexible) rectoscope under gas-filling of the rectum in the lithotomy, knee-elbow, or lateral position; most important method of examination for the early diagnosis of rectal carcinoma* (after previous digital examination), also obligatory in particular for the diagnosis of female genital carcinoma to exclude tumor invasion (e.g. in cervix carcinoma, vaginal carcinoma). rectum: 15-20 cm-long terminal section of the intestine which continues from the sigmoid at the cranial edge of the third sacral vertebra. In humans two constant curves in the sagittal plane: flexura sacralis, posteriorly convex, approximates the sacral curvature; flexura perinealis, anteriorly convex. Above Kohlrausch's valves the rectum is covered by peritoneum anteriorly and on both sides (retroperitoneally), below the peritoneal reflexion it lies extraperitoneally. rectus diastasis: abnormal gap between the rectus abdominis muscles (mm. recti abdominis) as a permanent condition; occurs after frequent births, abdominal operations. reduction mammoplasty: syn. reduction mastectomy; see mammoplasty. reflex, mamillary: erection of the nipple* (mamilla) on stimulation of the areola (areola mammae) through touch. reflexes, primitive: physiol. occurrence of a great number of reflexes and movement au-< tomatisms in the first weeks and months of life, which are gradually lost with increasing maturation of phylogenetically younger CNSstructures (neostriatum, cerebral cortex, and pyramidal tract). Characteristic of the primi-

reflexes, primitive

Primitive reflexes: 1: search reflex; 2: embrace reflex; 3: grasping reflex;4: vertebral column reflex; 5: stepping phenomenon tive reflexes (the absence or side-asymmetry of which, as well as their prolonged persistence, indicate a cerebral disorder; cf. palsy, cerebral) are the wide reflexogenic zones and the undifferentiated stimulus response through movement complexes (globus pallidus effect). The stimuli are mainly received by the skin receptors and by the labyrinth; the reflex arc proceeds via the thalamus and globus pallidus without involving the cerebrum. The primitive reflexes include in particular reflexes for the feeding, for the sense of position and movement, and postural reflexes. 1. the primitive reflexes for the feeding include the rooting reflex (see Fig.): stroking of the cheek leads to the mouth being pulled and the head turned in the direction of the stimulus; stroking of the lips leads to pursing of the mouth (mouth phenomenon) and to vigorous sucking movements, the sucking reflex. The swallowing reflex observed during feeding is also to be counted amongst these primitive reflexes, which disappear in about the 3rd month of life. 2. the primitive reflexes of the sense of position and movement, and postural reflexes include the palmar grasping reflex (see Fig.): in the first 6 months of life stroking the palms of the hand leads to flexion of the fingers and fist closure (increased when tugged). The plantar grasping reflex can be similarly elicited at the soles of the feet (roughly up to the 11th month of life); stepping phenomenon (see Fig.): when the child is held upright and the soles of his feet come into contact with the table, the newborn infant (1st month of life) carries out stepping movements (analogous to crawling movements in the abdominal position). Sudden pressure on the soles of the feet or contact over their entire surface brings about extension of all joints of the corresponding leg (readiness to stand) with simultaneous knee- and hip-flexion of the other, the so-called righting reflex (up to the 6th month of life); Galant's vertebral column reflex (see Fig.): stroking of the back to the side of the vertebral column leads to its curvature,

with the concavity being directed towards the stimulated side (disappears in the 3rd-6th month of life); asymmetrical tonic neck reflex (up to the 6th month of life): lateral rotation of the head brings about extension and an increase in tone of the arm lying towards the flight reflexes reaction of pupils to light palmar grasping reflex M o r o ' s reflex (1st phase) springing back of the legs (abdominal position) glabella-tap reflex cremasteric reflex search reflex springing back of the legs (dorsal position) springing back of the arms (dorsal position) uprighting reaction (bends in elbows)

--

··

--

M o r o ' s reflex ( 2 n d phase) uprighting reaction (head control) stepping p h e n o m e n o n raising of head in abdominal position

--

28

30 32 34 36 38 40 gestational age (weeks)

Primitive reflexes: Development of various reflexes and motor automatisms in the infant; dotted lines: not present in every case; dashes: development from immature to mature pattern; continuous line: developed form 207

r e f r a c t o r y period

face, with simultaneous flexion and a reduction in tone of the other arm (fencing position). Similar movements can often also be demonstrated at the lower extremity; symmetrical tonic neck reflex: bending the head backwards leads to extension and increased tone of the upper extremity with simultaneous flexion and reduced tone of the lower extremity. This movement-complex is reversed when the head is bent forwards. If this pathol. reflex persists, the child cannot crawl, but only hop like a frog; tonic neck extremities reflex (Magnus): passive rotation of the head brings about adduction of the contralateral leg (up to the 6th month). These tonic neck reflexes come about through a change in the position of the head in relation to the trunk, tonic labyrinthine reflexes through a change in the headand body-position in space. The latter include Moro's embrace reflex (startling response): if the table is suddenly jolted or the head allowed to fall back abruptly, the child extends his arms with splayed-out fingers (1st phase) and then slowly folds them over the chest again (2nd phase). Disappears in the 3rd-6th month of life. The stimulus response of the plantar reflex (stroking the soles of the feet) seen in newborn and infants (increasingly rarely also in small children) consists, prior to maturation of the pyramidal tract system, of withdrawal of the leg (flight reflex), elevation of the external margin of the foot (Monakow's sign), and dorsal flexion of one or several toes. The latter probably corresponds to the Babinski's sign. Flight reflexes can be elicited over the entire surface of the body even in immature-premature infants. In the glabella-tap reflex, the response to tapping the forehead is blinking (also excludes of a facial paralysis). The presence of certain movement automatisms and reflexes (see Fig.) permits a neurological determination of maturity analogous to the morphological determination (see maturity signs, neonatal).

symphysis, and below a horizontal line (interspinal line) connecting both spinae iliacae anteriores superiores. regio sacralis: sacral rhomboid, area above the os sacrum; bordered by the processus spinosus of the 5th lumbar vertebra, the end of the os sacrum, and two lateral pits (fossulae lumbales) over the superior posterior spines of the os ilium (spinae iliacae posteriores superiores). Cf. Michaelis' rhomboid. regio umbilicalis: area around the navel; bordered on each side by the medioclavicular lines, below by the interspinal lines (between the anterior superior spines of the ilium), and above by a plane laid at the lowest point of the arch of the ribs. regio urogenitalis: that area of the perineum lying in front of a line connecting both tuberosities of the ischium (part of the regio perinealis). regression syndrome, caudal: m a l f o r m a -

tions which occur with increased frequency in the infants of diabetic mothers, characterized in particular by a hypo- or agenesis of the caudal vertebral column and of the femurs. Malformations of various internal organs and also poly- and syndactyly of the toes may additionally occur. Cf. embryopathy, diabetic. relaxation, pelvic: estrogen-induced loosening of the symphyseal cartilage and of the e

refractory period: see s e x u a l r e s p o n s e (Ta-

ble). regio (Lat.): (anat.) region of the body, regio analis: that area of the perineum lying posterior to the connecting line drawn between both tuberosities of the ischium (part of the regio perinealis). regio glutaea: paired buttock area; region over the gluteal muscles. regiones inguinales: lateral sections of t h e

hypogastrium*; located outside of the medioclavicular line, above the inguinal ligaments, and below a horizontal line connecting both Spinae iliacae anteriores superiores.

Pelvic relaxation: Diagram of the arch construction of the pelvis and of the pressure and tractive forces acting upon the symphysis and ligaments; a: ligamentum sacrospinale; b: ligamentum sacrotuberale; c: ligamenta sacroiliaca ventralia; d: articulatio sacroiliaca; e: ligamenta sacroiliaca interossea etdorsalia; f: discus interpubicus

regiones laterales: a t t h e h e i g h t of t h e r e -

gio umbilicalis, areas of the abdominal wall lying lateral to the medioclavicular lines. regio perinealis: perineal area; between symphysis, os coccyx, and the tuberosities of the ischium; divided by a connecting line between the latter two into a regio* analis posterior and a regio* urogenitalis anterior. regio pubica: middle section of the hypogastrium; located within the medioclavicular lines, above the inguinal ligaments and the 208

sacroiliac joints during pregnancy; if the pelvic relaxation exceeds a certain degree, it represents a characteristic clinical picture; see also injury, symphyseal. release-inhibiting factors: also called release-inhibiting hormones (IH) and "statins", neurosecretions produced in the hypothalamus* (releasing* hormones) which inhibit the release of the hormones produced in the anterior pituitary lobe.

retention, urinary releasing factors: also called releasing hormones (RH) and "liberins", neurosecretions produced in the hypothalamus (releasing* hormones) which promote the release of the hormones produced in the anterior pituitary lobe. releasing hormones: abbr. RH; term used for the liberating („liberins") and inhibiting („statins") hormones produced in the hypothalamus* to control the anterior pituitary lobe hormones, see Table; short-chain, low molecular weight peptides, are synthesized in various nuclear regions of the hypothalamus (nucleus ventromedialis, nucleus praemamillaris, area praeoptica and suprachiasmatica). The highest concentrations are found in the hypophyseal stalk, where the RH are delivered via the neurovascular chain to the portal system of the hypophysis. The actions on the anterior lobe of the hypophysis* are mediated via hormone receptors; RH also stimulate hormone synthesis there. renal cortical necrosis: see necrosis, renal cortical. renal diabetes: see glycosuria, renal, repeat cesarean section: a repeated cesarean* section. resolution phase: see sexual response (Table). respiratory distress, neonatal: comprehensive term for all states of the newborn with cyanosis and dyspnea or tachypnea. Causes: hyaline* membrane disease (idiopathic neonatal respiratory distress), aspiration of amniotic fluid or meconium, pneumothorax, chylothorax, pneumonia, diaphragmatic hernia, phrenic nerve paresis, also choanal atresia,

congenital cardiac anomalies, cerebral disorders, etc. Cf. depression, neonatal; hypoxia test; CPAP. resuscitation (Lat. resuscitare to revive): (obst.) resuscitatory measures in neonatal depression* immediately after birth; e.g. aspiration of oral and pharyngeal space, trachea, stomach; intubation and ventilation (e.g. twophase method of Semm and Kriess: 1. distension of the asphyxial lungs through constant positive pressure, 5-20 sec., possibly several times; 2. rhythmic positive-negative pressure respiration), buffer therapy, treatment of shock, prevention of heat loss; cf. assessment, neonatal. resuscitation, intrauterine: treatment of fetal hypoxia during birth through pharmacological inhibition of contractions (see tocolysis), and a change of position (lateral position, position with elevation of the pelvis) as temporary measures until an emergency obstetric operation can be performed. retention cysts (Lat. retentare to hold back): (spurious) cysts formed by the retention of glandular secretions; e.g. atheroma, mucocele, mucous cysts, milk duct, or ovarian cysts. retention, urinary: the inability to urinate despite a full bladder; terms: ischuria (renal shutdown); postrenal anuria; causes: (gyn.) obstruction localized below the urinary bladder (massive prolapse with stop cock mechanism, large myomas) or detrusor atony (after extensive radical operations, chronic overstretching in infravesical obstruction); (obst.) protracted birth processes with compression of the urethra by the presenting part of the child.

Releasing hormones Hypothalamic releasing h o r m o n e s ' " Somatotropic hormones SRH/SIH MRH (PRH)/PIH Glandotropic hormones Gonatropic h o r m o n e s LH (FSH)-RH

Metabolotropic hormones TRH CRH

H o r m o n e s of the anterior pituitary lobe

Action

somatotropin (STH)

bone growth; mobilization of stores of fat a n d g l y c o g e n m e l a n o c y t e stimulating hor- dissemination of the m e l a n o mone (MSH) cytes prolactin milk formation; in a n i m a l s estrus

luteinizing h o r m o n e a n d interstitial cell stimulating hormone (LH/ICSH) follicle stimulating h o r m o n e (FSH)

formation of the sex h o r m o n e s in the o v a r i e s and testes

thryrotropic h o r m o n e (TSH) adrenocorticotropic hormone (ACTH)

production of thyroid h o r m o n e s production of a d r e n a l cortex hormones

d e v e l o p m e n t a n d maturation of the g a m e t e s

(1) The releasing h o r m o n e s (RH) a n d r e l e a s e inhibiting h o r m o n e s (IH) h a v e generic n a m e s which a r e d e r i v e d f r o m the n a m e s of the c o r r e s p o n d i n g anterior lobe hormones. 209

rate ovarii

rata ovarii (Lat. rete net): interlacing compact or reticular epithelial strands at the ovarian hilus (see ovarium); phylogenetically a homologue of the rete testis. rotinacula uteri (Lat retinaculum rope): supporting ligaments of the uterus* (see Fig.); the taut connective tissue strands surrounding the cervix, containing smooth muscle, and

lessen the severity of the retinopathy. All infants at risk should have an ophthalmological examination. retroflexion (Lai retro backward): flexion of the body of the uterus in a backwards di-

Retroflexion: Shown with the uterus in normal anteversion position; a: corpus axis; b: cervical axis

/Ayr

4W

Retinacula uteri

running in the subperitoneal connective tissue of the pelvis (parametrium*); attached mainly to the cervix* uteri in order to flexibly anchor the uterus. Important paired strands, the fanshaped lig. cardinale uteri (see lig. latum uteri) extend to the lateral pelvic walls, the lig. pubovesical extends anteriorly, and the plica rectouterine (see Douglas' pouch) posteriorly. Although not actually counting as part of the parametrial retinacula uteri, the ligamentum* teres uteri aids in the fixation of the uterus in that it holds the fundus anteriorly. At delivery the retinacula uteri prevent the uterus from slipping superiorly during labor. retinopathy of prematurity: syn. retrolen-

tal fibroplasia; an eye disorder leading to blindness with formation of vascular fibrous tissue behind the lens. Seen almost exclusively in premature infants* below 1500 g birth weight. Other risk factors are intracranial hemorrhages, sepsis, and especially oxygen therapy. Course: initially reversible dilatation and tortuosity of retinal vessels, then hemorrhages and neovascularization, retinal edema, and retinal detachment; sometimes glaucoma and shrinking of the eyeball. Prevention: careful dosage of oxygen in prematures, avoidance of hemorrhages, low hematocrit, and sepsis. Oral doses of vitamin Ε (100 mg/kg daily) may 210

rection towards the cervix. Forms: 1. mobile retroflexion (can be replaced during the examination); 2. fixed retroflexion (cannot be replaced because of adhesions to adjacent organs); causes: a) previous inflammations; b) endometriosis*. An operation is indicated only if there are relevant symptoms (see also ventrofixation); cf. flexion of uterus; uterus, version of; uterus, position of. retroflexion, fixed: fixation of the body of the bent uterus in retroflexion, through adhesions. retroflexion in pregnancy: if retroflexion*

is present, in rare cases reposition of the uterus may not occur after the commencement of a pregnancy and may lead to symptoms of incarceration (so-called retroflexio uteri gravidi incarcerata). Consequences: compression of the urethra with ischuria paradoxa; if untreated, abortion. retroplacental: behind the placenta, i.e. localized between the placenta and the wall of the uterus. retroposition: displacement of the entire uterus posteriorly; see uterus, position of. retropubic: lying behind the symphysis, retroversion: see uterus, version of. Rh-: see also Rhesus-, rhagadas, anal (Gr. rhagas, rhagados rent): superficial, striated, often painful, burning, and itching epithelial defects which usually take a course radially to the anus; not to be confused with anal fissures*. Not infrequently combined with anal eczema, hemorrhoids, or fungal infections (esp. candidiasis). Rh-arythroblaetosis: see erythroblastosis fetalis; erythroblastosis neonatorum. Rhesus system: syn. Rh-system, Rh-blood groups, Rh-factors; hereditary blood group properties on the surface of human erythrocytes. The various Rh-antigens (e.g. C, C", c, D, E, e) are heat-labile (probably proteins). They are demonstrated with the use of human antisera in the hemagglutination- or conglutination-test; a total of over 40 rhesus antigens is

rickets known. Inheritance is autosomal codominant The Rh-system is of practical importance in the determination of blood groups and crossmatching before transfusions (possible cause of a transfusion reaction or of an erythroblastosis* fetalis, neonatorum), for the determination of paternity*, in legal medicine, and also in autoimmune hemolytic anemias (Rhantibody as auto-antibody). Rh-immunoglobulin: see anti-D-prophylaxis. Rh-incompatibility: serological blood group intolerance in the Rhesus* system; of importance in obstetrics when there is the constellation of an Rh-negative mother and an Rh-positive father; in the event of an Rh-positive fetus and previous sensitization of the mother, there is the risk of an erythroblastosis* fetalis, neonatorum; cf. transfusion, fetomaternal. rhythm method: syn. Knaus-Ogino method (Hermann Knaus, gynecologist, Prague, Vienna, 1892-1970; Kyosaku Ogino, gynecologist, Japan, 1882-1975); independent of each other they both established the rhythm method for contraception* on a scientific basis. According to this, ovulation* in women always takes place on the 15th day (Knaus) or between the 12th and 16th day (Ogino) before the start of the next menstruation*. This is used as a basis for the method of contraception through periodic abstinence, which establishes the individual fertile days of the woman with the aid of a menstrual calendar (calendar method). Advantage: no physical side-effects; disadvantage: not very reliable (Pearl index according to data in the literature between 14 and 40). Therefore, if natural contraception* is desired, other methods should preferentially be used. rickets: defective calcification leading to malformation of the skeleton in childhood; on the basis of the therapeutic (and prophylactic) action of vitamin D, a distinction is drawn between vitamin-D-deficiency rickets and vitamin-D-resistant rickets. 1. vitamin-D-deficiency rickets is caused by a lack of ultraviolet rays (anactinosis): the photochemically active Dorno-rays (280-310 nm) convert 7-dehydrocholesterol synthesized by the body and stored in the epidermis into vitamin D 3

1

1 mf

v-V

: .

w

Rickets: Enamel hypoplasia as a late consequence of vitamin-D-deficiency rickets

through ring cleavage. According to recent investigations, the actual active substance seems to be an oxidation product of vitamin D (1,25-dihydroxycholecalciferol). Vitamin-D deficiency (especially during the winter months) reduces, among others, t h e absorption of calciu m from the intestine and t h e calcium exchange between the blood and t h e skeletal system and, because of t h e resulting hypocalcemia, leads to secondary hyperparathyroidism with increased mobilization of calcium f r o m the bones and increased phosphate excretion by the kidneys. Clinically the skeletal signs predominate and are rarely seen before the third month of life, usually in the 2nd six months of life, very rarely in older children (as late rickets). Following general restlessness, irritability, sleep disorders, head sweats, an increasing muscular hypotonia develops. Craniotabes is observed as t h e first skeletal sign. The metaphyseal growth zones of the long bones are tumefied through a disorder of cartilage breakdown and the deposition of non-calcifying osteoid, e.g. at the boundaries between the cartilage and bone of t h e ribs as the so-called rachitic rosary, at the distal ends of the long bones: cup-shaped dilatations (at the fingers:

Rickets: Albrecht Dürer's painting „Maria with the child" (1512, Kunsthistorisches Museum, Vienna) shows a full-blown picture of vitamin-D-deficiency rickets with caput quadratum, deformation of the thorax, flaccid abdominal wall, and tumefied epiphyses (double bosses) atthe joints of the hands and feet.

so-called beaded fingers, at the wrist and ankles: Marian's sign), at t h e skull: a quadrangular deformation (caput quadratum, "bossing"), at the protuberances of the frontal and parietal bones in connection with the craniotabetic flattening of the occiput, at t h e other parts of the skeleton: deformations and curvatures (kyphosis, bell-shaped thorax, narrowing of the pelvis, etc.). Skeletal maturation is delayed in the rachitic infant, the eruption of the milk 211

ridge, urogenital

teeth is also delayed and irregular. Therapy: oral (parenteral only in disorders of absorption) administration of vitamin D; monitoring of the radiological bone findings and laboratory findings. Vitamin-D-deficiency rickets can be prevented by systematic vitamin-D-prophylaxis. The physiological requirements are best met by the prolonged administration of 400-1000 IU daily from the 2nd week of life onwards. Premature infants are particularly predisposed to rickets because of the addition-

Rickets: Typical c h a n g e s of the hand bones with the formation of double bosses at the distal ends of the ulna and radius

al increased relative growth with higher mineral requirements. The uncontrolled administration of vitamin D puts the children at risk of vitamin-D-intoxication (nephrocalcinosis). 2. vitamin-D-resistant rickets does not respond to the administration of vitamin D in therapeutic doses. ridge,

urogenital:

embryonal

structure

(sexually indifferent) from which the gonads* develop, originating medially to the pronephros on both sides of the dorsal mesentery. The embryonal primordial germ cells (see gametogenesis) migrate into the urogenital ridge towards the end of the 6th week. rima ani (Lat. rima cleft): gluteal fold, rima pudendi: pudendal cleft; between the labia* majora pudendi. ring, umbilical: s e e u m b i l i c u s ,

Rokitansky- Küster- Hauser

syndrome

(Carl von Rokitansky, pathologist, Vienna, 1804-1878; Hermann Küster, gynecologist): congenital anomaly of the female genitalia secondary to inhibition of the müllerian ducts (embryol. development 2nd month); unknown etiology. Signs: hypoplasia of the external genitalia, vaginal aplasia or atresia, rudimentary uterus bicornis, which usually consists only of a thin tissue ridge without a cavity, high ovaries (Fig.); this explains the primary amenor-

Rokitansky-Küster-Hauser syndrome: Left: normal anatomy; right: RokitanskyKüster-Hauser syndrome

rhea, inability to copulate, and primary sterility. Since ovarian function is normal, secondary sexual characteristics are normally developed. Anomalies of the urogenital tract may be associated (dystopic single kidney, renal aplasia). Normal XX karyotype. rooming-in: accommodation of t h e n e w -

born and of the mother in the same room; constant contact in very early infancy is of fundamental importance for bonding between mother and child. The baby's father should also be able to visit frequently. Facilities for this should be made available in obstetric practice. Rosenfeld's syndrome (Eugene D. R o s e n -

feld, physician, New York): paraneoplastic syndrome with severe paroxysmal hypoglycemia in pseudomyxomas of the ovary, the appendix or the peritoneum, usually accompanied by ascites; the insulin concentration in the blood is normal. The causes of Rosenfeld's syndrome have not been elucidated.

ripening, cervical: change in the cervix in the sense of a readiness to relax; in the last weeks of pregnancy the cervix becomes softer, more flexible, more distensible, and shorter. Cf. birth, signs of. risk, anesthetic: see anesthetic risk. Ritgen's maneuver ( F e r d i n a n d von Ritgen,

gynecologist, Gießen, 1787-1867): syn. posterior perineal maneuver (see Fig.); the obstetrician speeds up the emergence of the head by applying pressure to the traversing head between the anus and tip of the coccyx. Rössle's syndrome (Robert Rössle, pathologist, Berlin, 1876-1956): see dysplasia, pure gonadal with dwarfism. Rohr's striae (Karl Rohr, gynecologist, Berne, 1863-1930): upper fibrin bands of the placenta; immediately adjacent to the intervillous space. 212

Rotor's syndrome (Arturo B. Rotor, internist, Manila): clinically largely corresponds to the Dubin*-Johnson syndrome, but is a less

rubella embryopathy marked (autosomal-dominant hereditary?) disorder of the excretion of bilirubin* (e.g. no pigment depositions in the liver). Diagnosis: pathological bromsulfalein test; the gallbladder is visualized on oral cholecystography. Hormonal contraception* is contraindicated. rubella: syn. German measles; apart from the high risk to the embryo, especially during the first three months of pregnancy if the mother has the disease (see rubella embryopathy), as a rule a harmless virus infection; causative pathogen: rubella* virus. Transmission through droplet infection. Spread: greatest incidence of the disease in children between the 3rd and 10th year of life; it is already contagious a few (2-4) days before the eruption of the typical exanthem and remains so at longest to the end of the exanthem stage. The contagiousness index is relatively low. Incubation period: c. 12-21 days. Clinical manifestation: after short (inconsistent) prodromal pyrexial stage (c. 2 days) with slight catarrhal symptoms in the region of the upper respiratory tract, occurrence of painless swelling of the lymph nodes (initially mostly nuchal and retroauricular, later generalized), simultaneously or shortly after this usually an exanthem (first on the face, then spreading to the trunk) in the form of not very raised and non-confluent pink-red spots about the size of a lentil, sometimes with a bright anemic areola, which fade after 2-3 days. In the throat meanwhile, there is a moderate macular exanthem. Fever usually only around 38 °C for a few days, splenomegaly in half of the cases; no particular impairment of general well-being. The disease almost always takes an uncomplicated course in children; in individual cases encephalitis and arthralgia of several joints (mostly in adolescents and adults) have been

observed. Late damage and cases of death are extremely rare. The diagnosis can be supported by the blood count (prodromal leukocytosis, in the clinical phase leukopenia with relative lymphocytosis, especially an increase in the plasma cells). Rubella prophylaxis: since 1981 active immunization has been recommended for all children regardless of their sex, given together with the measles-mumps vaccination; the rubella vaccination is repeated in the 10th-14th year of life. In women the rubella antibody titer should always be checked before a planned pregnancy (in the hemagglutination test 1:32 or more). If rubella antibodies are absent from the serum of pregnant women (e.g. after contact with a person with rubella), passive immunization is possible within the first 4 days of the incubation period using a special rubella hyperimmune globulin, which in the case of infection before the 6th week of pregnancy must be given again after 6 weeks. rubella embryopathy: syn. embryopathia rubeolosa, Gregg's syndrome; embryopathic malformation syndrome as a result of intrauterine rubella infection when the mother has contracted rubella* during the first three months of pregnancy. The constellation and severity of the manifestations depend on the time of the infection of the mother with rubella (in the first month of pregnancy usually eye anomalies, in the second month usually cardiac and CNS-anomalies, in the third month usually inner ear damage). According to more recent findings, there is also a risk to the fetus during the later phase of pregnancy (fetopathia rubeolosa). Signs: eyes: usually congenital cataracts, possibly with glaucoma, microphthalmia, changes of the f u n d u s of the eye (pseudoretinitis pigmentosa); heart: usually de-

Rubella embryopathy Nature and frequency of the malformations after prenatal rubella infection Signs of classic rubella embryopathy (Gregg's syndrome): Cardiac malformations Patent ductus arteriosus Aortic stenosis Ventricular septal defect Eye defects Cataract (uni- and bilateral) Retinopathy Glaucoma Hearing defect (uni- and bilateral; sensorineural) Other signs of congenital rubella infection: Cerebral damage Microcephaly, psychomotor or mental retardation Encephalitis (panencephalitis) up to the age of 10 years (including centrally induced deafness) Visceral damage Hepatosplenomegaly Thrombocytopenic purpura Bone changes (disorders of calcification) Disorders of development and growth (growth retardation, birth weight below 2500 g) Total lethality

52 - 8 8 %

50 - 5 5 %