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In this case the median is the 50th centile as it difference generic cialis professional 40 mg erectile dysfunction medicine from dabur, with either an increase or decrease after the describes the point where 50% of the population lie intervention order 40mg cialis professional with visa erectile dysfunction obesity. Similarly, the 90th cen- on the size of individual pair changes and is a measure of tile describes the value where 90% of the population are a population shift, although the problem with this is that below and 10% above and the 10th centile the value the changes could be very small but still statistically sig- where 10% are below and 90% are above. As with all statistics, the results must be inter- It has to be remembered that the normal range statisti- preted with clinical relevance. For example, if intrauterine growth restriction is classified as babies less than the 10th centile, then 10% of All the tests discussed have looked at ways of studying the normal baby population will fall into that category as populations if they are different. Further correlation between values within the population stud- evaluations are required to assess whether the baby is ied. These tests study the changes between two or more truly growth restricted or just a small normal baby. If two skewed or asymmetric popu- tistics cannot make this assumption and this has to be lations are to be compared, then non‐parametric tests interpreted by the investigator. The Term Breech Trial, with its large rand- just because the values are linked does not mean that omized format, convinced those who already believed they are causative; statistical dependence is not sufficient and some of those who were sceptical but others still to demonstrate the presence of such a relationship. The found flaws in the study so they did not have to change two variables may both be influenced independently by a their beliefs. This test is the Pearson correlation test, which tests for linear process is then repeated whenever additional evidence correlation. The nearer r is to 1 or −1, the closer the cor- is obtained, leading to a changing probability that the relation, implying that for each unit rise in one variable results are true or false. A value P can be given, similar to other statistical tests, stating the confidence that the test is Summary box 33. The square of the r value gives an approximation of the per- ● Mean: the sum of all the measurements divided by the centage effect the change of one variable has on the total number of measurements taken. It is only when r is of each individual measurement from the mean, cal- greater than 0. Bayesian inference is the use of a priori belief or prob- ● Centiles: describe the percentage of values contained ability about a test result to determine the probability within a given value range. In other words, knowing ● Mann–Whitney U test: a non‐parametric test for what we know from experience or belief, can this new assessing two independent populations. In day‐to‐day terms, this is the basis on ● Wilcoxon signed‐rank test: a paired non‐parametric how we change our beliefs and practices. However, as more evidence accumulates, the degree of ● Bayesian inference: a method that uses a priori belief confidence in a test result changes. With enough evi- or probability about a test result to determine the dence, the degree of confidence should become either probability that a new test result is true. This means that results will natu- rally be biased due to pre‐test prejudices but it allows the changing of that bias with more confirmatory evi- How we use statistics dence. Many observational studies suggested an increased This chapter has considered examples of how we use sta- risk of vaginal breech delivery but many practitioners tistics. Whatever the results, all are interpreted in the did not accept these results due to their pre‐existing light of our own experience. If we have no preconceived 472 Postnatal Care beliefs, we are open to the results of any trial. If we Statistics is a powerful tool in medical research and have a preconceived idea and the trial shows a null epidemiology, but it is important to use it at the right result, it confirms to us that what we do is correct, but time in the right way. If the wrong question is asked, the that is also true of people with a preconceived idea result is worthless irrespective of the outcome and statis- opposite to our own. It is important to think through the difference between immediate induction of labour or problem being addressed carefully and set the correct delay in cases of pre‐labour rupture of the membranes. This allowed people to continue to act as trial with insufficient numbers testing the wrong hypoth- they previously did, believing themselves to be correct, esis. It is also important to assess the results for clinical but it should have told people that there is no correct relevance and the consequences of changing actions answer and that women should be offered a choice of potentially resulting in unforeseen consequences that action. A prospective erythematosus: a population‐based retrospective study of unselected primiparous women: the Pregnancy cohort study with time‐to‐event analysis. The environment and disease: association or reexamined: still useful for clinical trials of causation? Where these the anatomy of the abdomen and the pelvis that should muscles coalesce in the midline, the linea alba is formed. Pyramidalis muscle is present in almost all women, origi- Many of the investigations and treatments we order on a nating on the anterior surface of the pubis and inserting daily basis require good anatomical knowledge in order into the linea alba. Surface anatomy the anterior abdominal wall can be divided into four the umbilicus quadrants by lines passing horizontally and vertically through the umbilicus. In the upper abdomen the umbilicus is essentially a scar made from the rem- is the epigastrium, which is the area just inferior to the nants of the umbilical cord. It is situated in the linea alba xiphisternum, and in the lower abdomen lie the right and and in a variable position depending on the obesity of left iliac fossae and the hypogastrium. However, the base of the umbilicus is always the cutaneous nerve supply of the anterior abdominal the thinnest part of the anterior abdominal wall and is the wall arises from the anterior rami of the lower thoracic commonest site of insertion of the primary port in lapa- and lumbar vertebrae. The urachus is the remains of the allantois from structures on the anterior abdominal wall are T7 (xiphi- the fetus and runs from the apex of the bladder to the sternum), T10 (umbilicus) and L1 (symphysis pubis). Occasionally this can remain patent in new- the blood supply is via the superior epigastric (branch borns. In early embryological life, the vitelline duct also of the internal thoracic artery) and the inferior epigastric runs through the umbilicus from the developing midgut. During lapa- Although the duct is severed long before delivery, a rem- roscopy, the inferior epigastric vessels can be seen between nant of this structure is found in 2% of the population as the peritoneum and rectus muscle on the anterior abdom- a Meckel’s diverticulum. The common iliac veins combine to taken to avoid them while using accessory trocars during form the inferior vena cava just below this and all these laparoscopy and to ensure that they are identified when structures are a potential hazard for the laparoscopist making a Maylard incision of the abdominal wall. The anterior abdominal wall Epithelium of the genital tract Beneath the skin and the fat of the superficial anterior the anterior abdominal wall including the vulva, vagina abdominal wall lies a sheath and combination of muscles and perineal areas are lined with squamous epithelium. This is an essential route for sperm to traverse in the process of fertilization but unfortunately it also allows the transport of pathological Superficial organisms that may result in ascending infection. In simplistic Fascia transversalis terms, it is probably best to imagine the pelvis containing the bladder, uterus and rectum. This complete layer is then pierced by both Extraperitoneal fat the fallopian tubes and the ovaries on each side. Posteriorly the rectum also pierces the peritoneum where it connects Skin to the sigmoid colon, and the area between the posterior Peritoneum surface of the uterus and its supporting ligaments and the Pubis rectum is called the pouch of Douglas. This particular area is important in gynaecology as the place where grav- ity‐dependent fluid collects. The bladder is lined by tran- pubis, labia majora and minora, and the opening into both sitional epithelium that becomes columnar as it lines the the vagina and urethra. The anal margin is still squamous epithelium areas of skin with underlying fat pads which bound the but this changes to columnar immediately inside the vagina.

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Even in the best centres with adequate moni­ pingectomies performed for hydrosalpinges purchase cialis professional 20mg on line do erectile dysfunction pills work, it is toring there can be a surprisingly brisk ovarian hoped that the incidence of ectopic pregnancy with response and the ovaries can hyperstimulate order cialis professional without a prescription erectile dysfunction what age. The cycle can be abandoned and then restarted at a lower dose or the eggs collected, fertilized and all the embryos electively Transvaginal oocyte retrieval frozen as severe hyperstimulation tends to be most There are always accepted risks of complications from serious in patients who become pregnant from a fresh ultrasound‐guided oocyte retrieval, and these can range transfer. Lastly, if the risks have been fully considered from infection of the ovaries causing ovarian abscess, and still thought acceptable, the embryos can be trans­ through to damage to the bowel. If the patient develops tense ascites, it can be drained on a daily basis, limited to 1 L Summary in multiple aliquots, as this often gives great relief and increases urinary output but avoids abrupt hypopro­ More than 5 million babies have now been born follow­ teinaemia. Assisted conception treatments continue to these also can be tapped, although draining the ascites grow internationally and in some developed countries helps these as well. Because of the increased risk of they now account for more than 2% of live births. There thromboembolism, patients should also receive throm­ has been a steady improvement in success rates due to boprophylaxis in the form of antithrombotic stockings scientific advances, despite the increased age of patients and low‐molecular‐weight heparin daily. Cryopreservation is proving to be an tion is deteriorating and the patient’s life is at risk, the increasingly important part of assisted conception treat­ pregnancy may need to be terminated. Assisted Reproduction 719 References 1 Strandell A, Lindhard A, Waldenstrom U, Thorburn J. Number of embryos for transfer 2 Strandell A, Bourne T, Bergh C, Granberg S, Asztely M, following in‐vitro fertilisation or intra‐cytoplasmic Thorburn J. A post prospective control study on the effect of Assisted reproductive technologies in the United intramural fibroids on the outcome of assisted States: 2000 results. Surgical treatment for experience in ovum donation using vitrified oocytes: tubal disease in women due to undergo in vitro report of cumulative outcomes, impact of storage time, fertilisation. Obstet Gynecol Clin North Am Timed intercourse versus intra‐uterine insemination 2005;32:55–67. Johnson 1Robinson Research Institute, University of Adelaide, Adelaide, Australia 2University of Auckland and Repromed Auckland and Auckland Gynaecology Group, Auckland, New Zealand 3World Entometriosis Society (2017–2020) the contemporary definition of endometriosisis is an direction along the fallopian tubes and the refluxed endo- inflammatory disease associated with pelvic pain or metrium then implants onto the surface of exposed tis- infertility that is characterized by lesions of endometrial‐ sues, principally the peritoneum. It is thus more than menstrual backflow seems important as higher preva- the presence of endometrial glands and stroma outside lence rates occur in women with increased menstrual the uterus, the experience of pelvic pain or infertility exposure due to (i) obstructed outflow associated with by women with the disease being the important defin- Müllerian anomalies, (ii) short menstrual cycles, (iii) ing features. It is preferable to take a patient‐centred increased duration of bleeding, and (iv) decreased parity approach to endometriosis, with a focus on patient‐cen- [6]. In addition, endometriosis is found more commonly tred outcomes, rather than the lesion‐based approach on the left side of the pelvis, thought to be due to the cleft that has been the hallmark of much clinical research in created by the sigmoid colon’s peritoneal reflections. However, Sampson’s theory does not explain all endome- Endometriosis affects approximately 176 million triosis since it can occur before menarche, in women with women of reproductive age worldwide [2]. While its amenorrhoea, despite menstrual suppression, at the underlying cause is uncertain, it is likely to be multifacto- umbilicus, and (incredibly rarely) in men. Hence the the- rial including genetic factors with epigenetic influences, ory of coelomic metaplasia, the pluripotential of coelomic and perhaps promoted through environmental expo- epithelium to develop not only into the more appropriate sures [3]. Endometriosis has elements of a pain syndrome normal tissue but also, through a programming defect, with central neurological sensitization [4], and is a prolif- into endometriotic tissue. Furthermore, despite the ubiq- erative, oestrogen‐dependent disorder with growing evi- uitous occurrence of retrograde menstruation, which dence of progesterone resistance [4]. There is overlap gynaecologists often view at the time of laparoscopy dur- with other conditions characterized by pelvic/abdominal ing menses, endometriosis occurs only in a minority of pain and infertility. Some symptomatic women with pel- women, and this is explained by the third theory, the con- vic pain who do not have diagnosed endometriosis may tribution of immunologic surveillance defects (which also benefit from similar treatments. The expression of factors such as cell adhesion molecules, proteolytic enzymes and cytokines affecting the adherence, implantation and pro- Epidemiology liferation of tissue within the peritoneal cavity may differ between women, as may clearance of endometrial cells Aetiology from the pelvis, and altered systemic humoral immunity the oldest proposal for the formation of endometriosis is (altered B‐cell function and antibody production) has Sampson’s theory of retrograde menstruation [5] or, more also been implicated. It is unclear whether such abnor- aptly, retrograde passage and implantation of endome- malities are truly a cause or a result of the disease. Menstrual material containing viable cells is embolic transport of endometrial cells through the blood transported into the peritoneal cavity in a retrograde and lymphatic stream may contribute to the very rare Dewhurst’s Textbook of Obstetrics & Gynaecology, Ninth Edition. One of the most appealing environ- pelvis, including lungs, brain and nasal tissues (responsi- mental exposure theories, that the environmental pollut- ble for the rare case reports, so loved by journal editors, ant dioxin might be an underlying cause of the disease [9], of catamenial pneumothorax and haemoptysis, catame- was ultimately difficult to confirm. The currently recognized nine endometriosis first‐degree relatives of affected women than in controls; gemetic loci explain only 3. Endometriosis is inherited as a complex genetic Prevalence trait, similar to diabetes or asthma, meaning that a number of genes interact to confer disease susceptibility, but the the prevalence is estimated to be 8–10% in women in phenotype probably only emerges in the presence of envi- the reproductive years [6]. Natural history of endometriosis [16], symptoms of endometriosis may also persist after and associated comorbidities natural or surgical menopause. Evidence is emerging regarding lescents with suggestive symptoms; in fact most women comorbidity for women with endometriosis. There may with endometriosis date the onset of symptoms to their be subtle associations with ovarian and breast cancers, teens [15]. Women with endometriosis appear to have a cutaneous melanoma, asthma and some autoimmune, higher risk of obstetric complications, including preterm cardiovascular and atopic diseases, and women with delivery, antepartum haemorrhage, pre‐eclampsia and endometriosis appear to be at decreased risk of cervical need for caesarean section, with rare occurrences of cancer [17]. Endometriosis has been recently shown to intra‐abdominal bleeding from endometriotic lesions have a significant association with coronary heart dis- requiring urgent surgery [1]. There with endometriosis become pain‐free after menopause is an association between endometriosis and clear‐cell, Endometriosis 725 low‐grade serous and endometrioid ovarian cancer [19], Peritoneal (or typical) endometriosis but the overall risk of ovarian cancer among women with Peritoneal endometriosis comprises superficial lesions endometriosis remains low, with a relative risk ranging scattered over the peritoneal, serosal and ovarian sur- from 1. The appearance has been described as ‘powder‐ time risk of ovarian cancer of no more than 1 in 100, burn’ or ‘gunshot’ deposits. Much more rarely, endometriosis may Cystic ovarian endometriosis present as an invasive disease while remaining histologi- (endometriomas) cally benign, with ascites, sometimes even pleural effu- Endometriomas develop as cystic lesions within the sions, and invasive lesions affecting not only the pelvis ovary, classically forming ‘chocolate cysts’ due to the deg- but also the diaphragm, bowel and abdominal side‐walls, radation of blood over time to a thick haemosiderin‐rich and thus may be impossible to distinguish clinically and fluid. Several variants on the implantation and metapla- on imaging from intra‐abdominal malignancy. Thus, it has been suggested that super- ficial lesions on the ovarian cortex become inverted and Endometriosis phenotypes at invaginated, and that endometriomas are derived from laparoscopy functional ovarian cysts or metaplasia of the coelomic epithelium covering the ovary. Endometriomas have fea- Although a stronger focus on the symptoms experienced tures in common with neoplasia such as clonal prolifera- by women and their outcomes is currently needed, it is tion, which is consistent with the endometriosis disease also important to retain an understanding of endome- theory. They are statistically associated with subtypes of triosis lesions, as this features prominently in the litera- ovarian malignancy, such as endometrioid and clear‐cell ture. However, it still remains uncertain whether lesions that are not absolutely typical often remain unrec- such cancers arise from malignant transformation of ognized by less experienced laparoscopists. Images (a), (b), (d) and (e) kindly contributed by Dr Michael East, Gynaecologist, Oxford Women’s Health, Christchurch, New Zealand. The ‘most subtle’ of all endometriotic lesions would be microscopic endo- Now defined as lesions extending deeper than 5mm metriosis [26], in other words the histological finding of under the peritoneal surface or those involving or dis- endometriosis in macroscopically normal peritoneum. Müllerian rests in the rectovaginal septum, and it has been proposed that deep endometriosis should be rede- fined as adenomyosis externa on pathological grounds Classification systems [23]. Numerous subtypes of deep the World Endometriosis Society consensus [21] identi- endometriosis have even be described. It remains unclear, however, whether with fertility outcomes and very poor correlation with these subtle lesions should be considered early disease, pain symptoms and quality of life, gives poor prognostic or whether they are transient physiological events information, and has poor predictive accuracy with respect to treatment outcomes [21].