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The age-related decline in 20 basal metabolic rate is not observed in women who continue to fungus journal order ketoconazole once a day be involved in a regular endurance exercise program fungus antibiotics ketoconazole 200 mg discount. A 30-year-old individual will inevitably gain weight if there is no change in caloric intake or exercise level over the years antifungal lip balm ketoconazole 200 mg fast delivery. It is fungus gnats in house uk buy ketoconazole 200 mg online, therefore, important for both our patients and ourselves to understand adipose tissue and the problem of obesity. Each cell of adipose tissue can be regarded as a package of triglyceride, the most concentrated form of stored energy. There are 8 calories per gram of triglyceride compared to 1 calorie per gram of glycogen. The total store of tissue and fluid carbohydrate in adults (about 300 calories) is inadequate to meet between-meal demands. Thus, obesity is a consequence of the fat imbalance inherent in high caloric diets. The mechanism for mobilizing energy from fat involves various enzymes and neurohormonal agents. Following ingestion of fat and its breakdown by gastric and pancreatic lipases, absorption of long-chain triglycerides and free fatty acids takes place in the small bowel. Chylomicrons (microscopic particles of fat) transferred through lymph channels into the systemic venous circulation are normally removed by hepatic parenchymal cells where a new lipoprotein is released into the circulation. When this lipoprotein is exposed to adipose tissue, lipolysis takes place through the action of lipoprotein lipase, an enzyme derived from the fat cells themselves. The fatty acids that are released then enter the fat cells where they are reesterified with glycerophosphate into triglycerides. Because alcohol diverts fat 21 from oxidation to storage, body weight is directly correlated with the level of alcohol consumption. The production and availability of glycerophosphate (required for reesterification of fatty acids and their storage as triglycerides) are considered rate limiting in lipogenesis, and this process depends on the presence of glucose. After esterification, subsequent lipolysis results in the release of fatty acids and glycerol. A low variable level of lipolysis takes place continuously; its basic function is to provide body heat. The chief metabolic products produced from fat are the circulating free fatty acids. When carbohydrate is in short supply, a flood of free fatty acids can be released. The free fatty acids in the peripheral circulation are almost wholly derived from endogenous triglycerides that undergo rapid hydrolysis to yield free fatty acid and glycerol. Free fatty acid release from adipose tissue is stimulated by physical exercise, fasting, exposure to cold, nervous tension, and anxiety. Omental, mesenteric, and subcutaneous fat is more labile and easily mobilized than fat from other sources. Areas from which energy is not easily mobilized are retrobulbar and perirenal fat where the tissue serves a structural function. Adipose tissue lipase is sensitive to stimulation by both epinephrine and norepinephrine. Lipase enzyme activity is inhibited by insulin, which appears to be alone as the major physiologic antagonist to the array of stimulating agents. When both glucose and insulin are abundant, transport of glucose into fat cells is high, and glycerophosphate production increases to esterify fatty acids. The carbohydrate and fat composition of the fuel supply is constantly changing, depending on stresses and demands. Because the central nervous system and some other tissues can utilize only glucose for energy, a homeostatic mechanism for conserving carbohydrate is essential. When glucose is abundant and easily available, it is utilized in adipose tissue for producing glycerophosphate to immobilize fatty acids as triglycerides. The circulating level of free fatty acids in muscle will, therefore, be low, and glucose will be used by all of the tissues. When carbohydrate is scarce, the amount of glucose reaching the fat cells declines, and glycerophosphate production is reduced. The fat cell releases fatty acids, and their circulating levels rise to a point where glycolysis is inhibited. In the simplest terms, when a person eats, glucose is available, insulin is secreted, and fat is stored. In starvation, the glucose level falls, insulin secretion decreases, and fat is mobilized. If only single large meals are consumed, the body learns to convert carbohydrate to fat very quickly. Epidemiologic studies with schoolchildren demonstrate a positive 17 correlation between fewer meals and a greater tendency toward obesity. The person who does not eat all day and then stocks up at night is perhaps doing the worst possible thing. Clinical Obesity Leptin and the Ob Gene (the Lep Gene in Humans) the hypothalamic location of the appetite center was established in 1940 by the demonstration that bilateral lesions of the ventromedial nucleus produce experimental obesity in rats. Interestingly, this pattern is similar to that seen in human beings the pressure to eat is reinforced by the desire to be physically inactive. The ventromedial nucleus was thought to represent an integrating center for appetite and hunger information. Destruction of the ventromedial nucleus was believed to result in a loss of satiety signals, leading to hyperphagia. Overeating and obesity, however, are not due to 22 ventromedial nucleus damage but rather to destruction of the nearby ventral noradrenergic bundle. Hypothalamic noradrenergic terminals are derived from long fibers ascending from hindbrain cell bodies. Lesions of the ventromedial nucleus produced by radiofrequency current fail to cause obesity. These lesions lead to overeating and obesity only when they extend beyond the ventromedial nucleus. Opiates, substance P, and cholecystokinin play a role in mediating taste, the gatekeeper for 23 feeding, while peptides released from the stomach and intestine act as satiety signals. Although recent attention has focused on leptin and the ob gene, keep in mind that the control of food intake and energy expenditure is very complex, and no agent or system functions in isolation. Leptin is a 167-amino acid peptide secreted in adipose tissue, that circulates in the blood bound to a family of proteins, and acts on the central nervous system neurons that regulate eating behavior and energy balance. Rat studies in the 25, 26 1950s suggested the existence of a hormone in adipose tissue that regulated body weight through an interaction with the hypothalamus. But it was not until 1994 27 that the ob gene was identified, the gene responsible for obesity in the mouse. Fat/fat mice are obese and remain insulin sensitive; the mutation decreases carboxypeptidase E, an enzyme that is involved in the conversion of prohormones to hormones;. Genetic Rodent Models of Obesity Single Gene Mutations Gene Product Rodent Chromosome Human Chromosome Mice: ob/ob Leptin 6 7 db/db Leptin receptor 4 1 fat/fat Carboxypeptidase E 8 11 tub/tub Phosphodiesterase 7 4 Ay/Ay Agouti protein 2 20 Rats: fa/fa Leptin receptor 5 1 Ob/ob and db/db mice were described over 30 years ago. The ob/ob mutation arose spontaneously in the Jackson Laboratory mouse colony in 1949. The ob/ob mouse is homozygous for a mutation of the ob gene on chromosome 6, and the db/db mouse, discovered in 1966, is homozygous for a mutation of the db gene on 28, 29 chromosome 4. The product of the ob gene is leptin, and in the human, the Lep gene is located on chromosome 7q31, 3. Thus, the ob/ob mouse is obese because it does not produce leptin, and the db mouse is obese because it cannot respond to leptin; its leptin levels are very high (the mutation alters the leptin receptor). The Leptin Receptor 29 the leptin receptor belongs to the cytokine receptor family. The intracellular domain of the short form contains 34 amino acids, and in the long form, about 303 amino acids. The short form has many variations, whereas the long form is the likely signaling receptor. The only place that the long form is expressed in greater amounts than the short forms is in the 30, 31 hypothalamus, in the arcuate, ventromedial, paraventricular, and dorsomedial nuclei. High levels of the short form leptin receptors in the choroid plexus suggest a transport role for the short form from blood into the cerebrospinal fluid to diffuse into the 32 33 brain. The db/db mouse has a single G for T nucleotide substitution within the C terminal untranslated end of the short intracellular domain of the ob receptor.

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Most drugs will enter breast milk; therefore fungus jelly discount 200mg ketoconazole overnight delivery, one must consider this when counseling and prescribing for breastfeeding mothers antifungal liver order ketoconazole with a visa. IgA is the primary antibody contained in breast milk and appears to fungus resistant tomatoes purchase ketoconazole prevent many gastrointestinal infectious complications for newborns antifungal treatment for ringworm ketoconazole 200mg visa. These predispose to thromboembolic phenomena and have a significant occurrence of rebound engorgement as the hormonal influence decreases. Bromocriptine, via a decrease in prolactin levels, was tried, but there was an association with hypertension, stroke, and seizure with its use. The safest treatment is a binder of the breast, ice packs, and analgesics for the first week postpartum. Treatment of mastitis includes antibiotics, continuance of nursing, and drainage of any abscess. Argument exists as to the method of skin incision for drainage of breast abscesses. Cir-cumareolar skin incisions following Langers skin lines are advocated by some for cosmetic reasons. Identification of possible nosocomial infection is important since infants may be colonized by nursery staff in the hospital who are carriers of resistant strains of Staphylococcusand other organisms. Fewer authorities now recommend the discontinuance of nursing, although the need to empty the breast is still emphasized. As they have marked anti-insulin effects, the rapid loss may account for part of the decrease in the insulin requirement often seen in postpartum diabetic patients. One should be careful not to give too large an insulin dose, which might precipitate insulin shock in the postpartum patient. A soft or boggy uterus usually signifies lack of tonus and the diagnosis of atony. A pelvic examination should be done whenever there is urinary retention postpartum. Delivery usually causes some trauma to the base of the bladder and trigone, and edema and ecchymosis are common. Anesthesia and/or overdistention may result in poor bladder function for varying periods of time, but all of these will usually resolve with a short time of catheterization. Prolonged bladder distention can cause pain, detrusor injury, and uterine atony with delayed hemorrhage. However, measurements have shown that a blood loss of 500 to 600 mL is quite common. This is because the expanded blood volume during pregnancy is like having two autologous units for transfusion. Some of the basal endometrium is located between myometrial fibers and will usually remain, even after a D&C. If recognized early before administering postpartum oxytocin or contraction of the lower uterine segment, replacement is easy. Bleeding and hypotension out of proportion to blood loss are the greatest dangers. It causes uterine distention when the desired effect is contraction of the muscle fibers to occlude bleeding vessels. A B-Lynch suture involves an exploratory laparotomy and would be done just prior to proceeding with a hysterectomy if the bleeding is not controlled. A D&C is useful if one feels that retained placental fragments are causing the bleeding. Although Ergotrate is very effective for treating uterine atony, they can cause a dangerous increase in blood pressure in women who are already hypertensive. An infant is born and at 5 minutes it has a vigorous cry, a heart rate of 105, movement of all four extremities, grimacing with stimulation, and has bluish hands and feet. Newborns who are allowed to remain at room temperature immediately after delivery rather than warmed by skin-to-skin contact with mom or placement in a warmer are at risk for the development of which of the following Which of the following is the most common cause of failure to establish effective respiratory effort in the newborn A patient with no prenatal care presents in labor claiming to be at 43 weeks of gestation. Which of the following neonatal findings would support the diagnosis of a postmature infant Five infants are admitted to the newborn nursery after uncomplicated vaginal deliveries. Which of the following newborns would be classified as high-risk and merits closer monitoring On the 5th day of life, how would the weight of a term infant that weighed 7 lb, 8 oz at birth be expected to change The first-time mother of a newborn would like to know about the care of the umbilical cord stump. It is noted to have an Apgar score of 3 at 1 minute and later to be irritable and restless. A heroin-abusing woman presents to labor and delivery and has a precipitous vaginal delivery of a term infant who has poor respiratory effort and Apgar scores 2/4/6. Rather than simply sedation from narcotic abuse, what is the most likely finding in a neonate with intrapartum asphyxia After a delivery complicated by a shoulder dystocia, a newborn is found to have paralysis of one arm with the forearm extended and rotated inward next to the trunk. When faced with the delivery of a premature newborn, the normal resuscitation should be altered to routinely include which of the following At a new obstetrics visit, a nulliparous patient shares her fears of having a neonatal death because her mother had a child with a neonatal death. In counseling the patient, you explain that, in the United States, which of the following is the most common factor associated with neonatal death A premature newborn exhibits rapid grunting respiration, chest retraction, and a diffuse infiltrate in the lung fields demonstrated on chest X-ray. After a normal labor and delivery of monozygotic twins at 35 weeks of gestation, one is found to be polycythemic, and the other small and markedly anemic. Approximately 2 days after delivery, an apparently healthy newborn male infant develops an intracranial hemorrhage. The bleeding time is normal for age, but the prothrombin time is greatly prolonged. A premature newborn is found to have abdominal distention, ileus, and bloody stools. An abdominal x-ray shows excessive gas in the bowel and free air under the diaphragm. He is noted to have low-set ears, contractures of the extremities, and prominent epicanthal folds. Neurologic abnormalities are found in greatest proportion in infants with which of the following An infant was born 10 hours previously to a mother whose membranes ruptured 27 hours prior to delivery. A patient who is a practicing veterinarian is concerned about contracting toxoplasmosis from her feline patients. In counseling the patient, what do you note as the most common sequela of a fetal toxoplasmosis infection While counseling a mother on the risks of a child having a trisomy 21 after second-trimester screening, you note that the general background incidence of significant fetal malformations (birth defects) is approximately which of the following Widespread use of thalidomide in Europe in the mid-1980s was clearly associated with birth defects. This is because when used in the first trimester, thalidomide is associated with phocomelia, which is defined as a defect in the development of which of the following The genital folds (scrotum and labia minora) are adherent in the midline, and there is severe hypospadias. Your best response, based on the information given, should be which of the following A patient who reports episodes of binge drinking in the first trimester wants evaluation of the fetus for fetal alcohol syndrome so she might terminate the pregnancy if it is affected. You inform her that antenatal testing is unable to detect the physical manifestations of fetal alcohol syndrome and it is associated with which of the following A patient with no prenatal care delivers shortly after arriving in the labor and delivery suite. At 5 minutes after resuscitation efforts, the infant has a pink body, blue fingers, vigorous cry and active motion, good respiration, and heart rate of 120 bpm.

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In the rest of the world fungus gnats mosquito bits purchase ketoconazole 200 mg with visa, contraceptive services can be obtained from more accessible resources and relatively inexpensively fungus spores generic ketoconazole 200 mg amex. Major problems are the enormous diversity of people and the unequal distribution of income in the U antifungal for toes purchase ketoconazole 200 mg line. These factors influence the ability of our society to fungus gnats ground cinnamon buy ketoconazole overnight effectively provide education regarding sex and contraception and to effectively make contraception services available. The era of modern contraception dates from 1960 when oral contraception was first approved by the U. The clinician must be aware of the definitions and measurements used in assessing contraceptive efficacy and must draw on the talents of appropriate experts in this area to summarize the accurate and comparative failure rates for the various methods of contraception. Definition and Measurement Contraceptive efficacy is generally assessed by measuring the number of unplanned pregnancies that occur during a specified period of exposure and use of a contraceptive method. The two methods that have been used to measure contraceptive efficacy are the Pearl index and life-table analysis. The Pearl Index the Pearl index is defined as the number of failures per 100 woman-years of exposure. The denominator is the total months or cycles of exposure from the onset of a method until completion of the study, an unintended pregnancy, or discontinuation of the method. The quotient is multiplied by 1200 if the denominator consists of months or by 1300 if the denominator consists of cycles. The Pearl index is usually based on a lengthy exposure (usually one year) and, therefore, fails to accurately compare methods at various durations of exposure. Life-Table Analysis Life-table analysis calculates a failure rate for each month of use. A cumulative failure rate can then compare methods for any specific length of exposure. Women who leave a study for any reason other than unintended pregnancy are removed from the analysis, contributing their exposure until the time of the exit. Thus, method effectiveness and use effectiveness have been used to designate efficacy with correct and incorrect use of a method. It is less confusing to simply compare the very best performance (the lowest expected failure rate) with the usual experience (typical failure rates) as noted in the table of failure rates during the first year of use. The lowest expected failure rates are determined in clinical trials, where the combination of highly motivated subjects and frequent support from the study personnel yields the best results. It should be noted that slightly more than half of the unintended 4 pregnancies in the U. Contraceptive Use in the United States the National Survey of Family Growth is conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention. The percent of married couples using sterilization as a method of contraception more than doubled from 1972 to 1988, and has remained stable since then. The use of oral contraception reached a high in 1992, and then decreased in 1995, especially among Hispanic and black Americans. Among never married women, oral contraception has been the leading method of birth control, but from 1988 to 1995, oral contraceptive use decreased in women younger than 25 and rose among women aged 3044. A part of the decrease in oral contraceptive use is due to the new availability and use of implant (about 0. However, the greater impact is due to an increase in condom use, especially by never married and formerly married women, women younger than 25, black women, and Hispanic women; indeed, the recent increase in overall contraceptive use is due to the increase in condom use which rose from 5. About one-third of condom users in 1995 were using more than one method, especially younger and never married women! However, studies have repeatedly documented that the use of the implant and injectable 12, 13 methods is associated with lower discontinuation rates and a lower rate of repeat pregnancies following delivery. In 1995, 95% of those who were at risk of getting pregnant were using some method of contraception, whereas 36% of women of reproductive age were not using a method of contraception for the following reasons: 11%no sexual experience, 9% pregnant or trying to get pregnant, 6% not sexually active, 5% sterilized for medical reasons, 5% at risk for an unintended pregnancy (this percentage steadily decreased over the last decade). Between 1973 and 1982, oral contraception and sterilization changed places as the most popular contraceptive method among women over the age of 30. Approximately one-half of American couples choose sterilization within 15 to 20 years of their last wanted birth. During the years of maximal fertility, oral contraceptives are the most common method peaking at age 2024. The use of condoms is the second most widely used method of reversible contraception, rising from about 9% in the mid 1980s to approximately 20% of 11 couples in 1995. The Impact of the Worldwide Use of Contraception 16 the world population is expected to stabilize at between 11 and 12 billion around 2150, with a fertility rate of 2. Approximately 95% of the 17 growth will occur in developing countries, so that by 2100, 13% of the population will live in developed countries, a decrease from the current 25%. Less than 15% of women of reproductive age in the world are using oral contraceptives, and more than half live in the U. The ability to regulate fertility has a significant impact on infant, child, and maternal mortality and morbidity. A pregnant woman has a 200 times greater chance of dying living in a developing country than in a developed country. The health risks associated with pregnancy and 19 childbirth in the developing world are far greater than risks secondary to the use of modern contraception. In recent years, there has been an appropriate shift from a narrow focus on contraception to a broader view that encompasses the impact of poverty, emphasizes 20 overall well-being and the rights of individuals, endorses gender equality, and examines the interactions among these issues. It is not enough to simply limit fertility; contraception is only one component of reproductive health. The Impact of Use and Non-use Inadequate access to contraception is associated with a high induced abortion rate. Effective contraceptive use largely, although not totally, replaces the resort to 21 abortion. The combination of restrictive abortion laws and the lack of safe abortion services continues to make unsafe abortion a major cause of morbidity and mortality throughout the world. Both safe and unsafe abortions can be minimized by maximizing contraceptive services. States 23 with higher family planning expenditures have fewer induced abortions, low-birthweight newborns, and premature births. The investment in family planning leads to short-term reductions in expenditures on maternal and child health services and after 5 years, a reduction in costs for education budgets. Cutting back on publicly funded family planning services impacts largely on poor women, increasing the number of unintended births and abortions. There is a gap between the low levels of unintentional pregnancy that can be achieved and the actual levels being obtained, most of which are in couples using reversible contraception. A major thrust, in addition to providing services, must include education and counseling of couples about effective contraception. The modification of unsafe sexual practices reduces the risk of unplanned pregnancy and the risk of infections of the reproductive tract. The Future 26 From 1970 to 1986, the number of births in women over 30 quadrupled; since 1990, the fertility rate among women over 30 has remained relatively stable. As more and more couples defer pregnancy until later in life, the use of sterilization under age 35 will decline, and the need for reversible contraception will increase. Between 11 1988 and 1995, oral contraceptive use decreased in women younger than 25 and increased in women aged 3044. These numbers changed because clinicians and patients have come to understand and accept that low-dose oral contraception is safe for healthy, nonsmoking older women. The need for reversible contraception in women over the age of 30 is growing, not diminishing. The entire cohort of women born in this period will not reach their 45th birthday until around 2010. For approximately a 20-year period, therefore, there will be an unprecedented number of women in the later childbearing years. The proportion of births accounted for by this group of women will 27 increase by about 72%, from 5% in 1982 to 8. This group of women is not only increasing in number, but it is changing its fertility pattern. But only 16% of the decline in the total fertility rate is accounted for by the increase in the average age at first marriage. Eighty-three percent of the decline in total fertility rate is accounted for by changes in marital fertility rates.

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The most critical period for amelia is from the 27th to antifungal for candida purchase ketoconazole 200 mg with amex the 30th day of development antifungal paint order ketoconazole 200 mg fast delivery. Anticonvulsant Embryopathy Anticonvulsants (hydantoin antifungal hand buy ketoconazole uk, phenytoin fungus like protist examples order ketoconazole without prescription, carbamazepine, valproic acid, and Table 10. Polytherapy presents a greater risk formajormalformationsthanmonotherapy, buttherelativerisksofmonother apy versus polytherapy remain unresolved. Vitamin A Congener (Isotretinoin, Etretinate) Embryopathy Current data indicate that use of isotretinoin or etretinate at 0. State study and modified to account for inflation) United States around 4 billion dollars per year Wisconsin around 90 million dollars per year Table 10. If exposure takes place within the rst 10 weeks after conception, at least 35% of pregnancies result in malformed infants or in spontaneous abortions. Growth retardation Dysmorphic facial features include: Mental retardation Cleft palate facial asymmetry with midface hypoplasia Cardiac defects metopic synostosis microphthalmia oculomotor palsies Table 10. Small head V-shaped eyebrows Synophrys Ptosis Strabismus Epicanthal folds Dysplastic ears Low-set ears Hearing loss Small nose Anteverted nares, Depressed nasal bridge midface hypoplasia, mild micrognathia Similar facial features in older Table 10. Facial dysmorphism Warfarin prevents the reduction of vitamin K with consequent gamma car Chondrodysplasia punctata boxyglutamation of osteocalcin that is deposited in fetal cartilage. Brachycephaly Hypertelorism Blepharophimosis Epicanthal folds Low-set ears Short stature, Micrognathia low birth weight for gestational age Mesomelic shortening of forearms Talipes equinovarus Table 10. The deciduous teeth present a yellow to brownish discoloration of the crown located primarily near the gingival third of the incisors and the occlusal and incisal third of the molars and canines, respectively. Note widows peak, hypoplastic eye larger surface is stained, and enamel hypoplasia is often found. As the teeth become brown, uorescence under ultraviolet light progressively declines. An increase in the expected frequency of cardio vascular defects and hypospadias has also been reported but is not well documented. The mother was exposed to high doses of Primatene (ephedrine, theo phylline, phenobarbital) throughout pregnancy. However, females with the disor der who are not diet protected during their pregnancy nearly always give birth to infants with intrauterine and postnatal growth retardation, microcephaly, mental retardation, congenital heart anomalies, dislocated hips, and other de fects. When maternal phenylalanine exceeds 20 mg per deciliter, 95% of their infants have mental retardation, 73% have microcephaly, 40% have intrauterine growth retardation, and 12% cardiac anomalies. Toluene Embryopathy Toluene embryopathy is a consequence of solvent abuse (spray paint, lacquer or glue snif ng) (Figure 10. Toluene easily crosses the placenta, producing changes in infants very rem iniscent of those seen in fetal alcohol embryopathy. Both toluene and alcohol embryopathy probably result from a common insult to the mesoderm ventral to the forebrain. Infant stillborn with cleft lip, Note microcephaly, midfacial hypoplasia, and palate due to maternal prednisone. The most likely mechanism for cocaine causing vascular disruption is al teration of blood ow at the uterine-placental unit by a direct effect on the embryonic-fetal vasculature with increase in blood pressure, and/or the effects of toxic oxygen-free radicals. Most frequently noted are anomalies of the cardiovascular, genitourinary, andcentralnervoussystems. Inaddition, infantswithcaudaldysplasia, femoral hypoplasia, and unusual facies are born more frequently to diabetic mothers. Alteration in blood ow to the uterine-placental unit, from either chronic or acute reduction of uterine blood supply, affects the developing embryo and fetus (Tables 10. Infant of diabetic mother with amelia Renal defects ofupperlimbs, cleftlip, andcaudaldysplasia. Encephaloclastic Lesions Encephaloclastic lesions can result from insults during the fetal period, at birth, or postnatally. Multicystic encephalomalacia has been reported in twins and is thought to result in multiple emboli occluding cerebral vessels resulting in Swiss cheese brain. Isolated limb anomalies, especially terminal transverse defects that are sporadic, may be due to vascular disruption. Transverse limb defects, absent limbs, and limb girdles may result from extensive involvement by a hematoma or disruption during early limb bud formation. The limb body wall malformation complex results from a malfunction in the ectodermal placodes. The amnio-ectodermal transition zone plays an important role in the for mation of the ventral body wall. A surface ectoderm placode is at the transition zone, depositing mesectodermal cells that will form the mesodermal structures of the body wall. Placodes are specialized parts of the surface ectoderm that add cells to the mesodermal compartment. They are involved in the formation of many or gans and structures, including the neural tube, nose, branchial arches, ventral body wall, and limbs. When these ectodermal placodes do not function cor rectly, the mesoderm remains underdeveloped and severe malformations may be expected. In secondary abdominoschisis the body wall placode is de cient in deposit ing mesoectodermal cells after the amnioectodermal transition zone has at tached to the connecting stalk, and the body cavity has separated from the extraembryonic coelom. The body wall remains very thin and eventually rup tures because of the increase of the abdominal and/or the thoracic organs. The margins of such a body wall defect are smooth and show a transition from skin into the mesothelium of the body cavity. Small developmental defects in the mesodermal compartment can easily result in severe limb malformations due to abnormal function of the limb bud placodes. Thisischaracterizedbyseverecleftsoftheabdominal wall with absence of, or very small, umbilical cord, or it is continuous with the placenta. Classically, pleurosomas refers to body wall and upper limb defects, and cyllosomas to body wall de ciency and lower limb defects. In 72% of fetuses, the internal anomalies are recognized to be secondary to vascular disruption. Ultrasonography Cloacal exstrophy absent bladder, lumbo-sacral neural tube, single umbil ical artery. Gastroschisis Gastroschisis is an abdominal wall defect lateral to the umbilical cord (more commonly on the left) (Figures 10. The extrusion of abdomi nal organs is into the amniotic cavity rather than the extracoelomic space, as occurs in a body wall defect. Gastroschisis appears to result from premature ablation and/or disruption of the embryonic omphalomesenteric artery. The resultant abdominal wall defect leads to extrusion of abdominal contents into the amniotic cavity. Associated structural anomalies in the gastrointestinal tract are present in 4050% of cases. Frequent associated anomalies include nonduodenal intesti nalatresiaorstenosis, atresiaoftheappendix, atresiaofthegallbladder, absence of one kidney, hydronephrosis and hydroureters, and porencephaly. Fetus with amniotic bands resulting raco-abdominal wall defect, ectopia cordis in disruption of head, fingers, and toes. Emboli from the placenta to both monogygotis twins, causing death of one twin and structural anomalies from embolic infarction in the surviving twin. Thromboplastin from the demised co-twin causing disseminated intravas cular coagulation and structural anomalies in the surviving twin (Swiss cheese brain). Disparateplacentalblood ow(maternal-placentalunit)resultinginaltered growth and anomalies from hypo to hyperperfusion. Craniofacial clefts with ectopia cordis Almost always lethal Usually neonatal lethal iii. Pierre Robin sequence secondary to Good fetal period (712 weeks) transient oligohydramnios ii. Ad hesive bands are the result of a broad fusion between disrupted fetal parts (mostly cephalic) and an intact amniotic membrane. Most of the craniofacial defects (encephaloceles and/or facial clefts) occurring in these fetuses are not causedbyconstrictiveamnioticbandsbutaretheresultofavasculardisruption sequence with or without cephalo-amniotic adhesion. The type of anomalies depends on the stage of embryonic development and the severity of the disruptive event. The amniotic membrane sometimes may become attached to areas of cell death or imperfect histogenesis in the fetus; in this way, amniotic bands can be formed secondary to the malformations.