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These levels are as into the azygos and hemiazygos systems (see Fig discount reminyl 4 mg with mastercard symptoms stiff neck. Lymph drainage from the: • T10 purchase reminyl 8 mg on-line medications are administered to, the oesophageal opening: transmits the oesophagus, vagi and • Anterior chest wall: is to the anterior axillary nodes. The left phrenic nerve passes into the diaphragm as a solitary structure. Only the upper six intercostal nerves run in their inter- • Motor supply: the entire motor supply arises from the phrenic nerves costal spaces, the remainder gaining access to the anterior abdominal (C3,4,5). Diaphragmatic contraction is the mainstay of inspiration. The sensory supply from the • Cutaneous anterior and lateral branches. The thoracic wall II 9 3 The mediastinum Icthe contents of the mediastinum Superior mediastinum Great vessels Trachea Oesophagus Thymus, etc. Middle mediastinum Heart and roots of great vessels Anterior mediastinum Pericardium Thymus Posterior mediastinum Oesophagus Descending thoracic aorta Thoracic duct Fig. The superior mediastinum communicates with the root of the neck The dual drainage of the lower third forms a site of portal-systemic through the ‘thoracic inlet’. The latter opening is bounded anteriorly by anastomosis. In advanced liver cirrhosis, portal pressure rises result- the manubrium, posteriorly by T1 vertebra and laterally by the 1st rib. These veins become distended and fragile (oesophageal varices). They are predisposed to rupture, causing potentially life-threatening • Middle mediastinum: consists of the pericardium and heart. The lower oesophagus also drains into the nodes The contents of the mediastinum (Figs 3. The oesophagus Carcinoma of the oesophagus carries an extremely poor prognosis. In the thorax the oesoph- account for the majority of tumours. The incidence of adenocarcinoma of agus passes initially through the superior and then the posterior medi- the lower third of the oesophagus is currently increasing for unknown astina. Having deviated slightly to the left in the neck the oesophagus reasons. Most tumours are unresectable at the time of diagnosis. The returns to the midline in the thorax at the level of T5. From here, it insertion of stents and use of lasers to pass through tumour obstruction passes downwards and forwards to reach the oesophageal opening in have become the principal methods of palliation. It is situated between the abdom- • A double muscular layeralongitudinal outer layer and circular inal aorta and the right crus of the diaphragm. The muscle is striated in the upper two-thirds and • The thoracic duct carries lymph from the cisterna chyli through the smooth in the lower third. It usually receives • An outer layer of areolar tissue. On trunks, although they may open into the large neck veins directly. After puberty the thymus is gradually replaced by fat. The mediastinum Ibthe contents of the mediastinum 11 4 The mediastinum IIcthe vessels of the thorax Inferior thyroid Inferior laryngeal Superficial cervical Thyroidea ima Suprascapular Costocervical trunk Thyrocervical trunk Vertebral Deep cervical Scalenus anterior Dorsal scapular Superior intercostal Subclavian Upper two posterior Internal thoracic (mammary) intercostals Anterior intercostals Musculophrenic Brachiocephalic Superior epigastric Posterior intercostals (also supply spinal cord) Bronchial Oesophageal branches Mediastinal Subcostal Fig. The internal thoracic artery divides behind the 6th The ascending aorta arises from the aortic vestibule behind the costal cartilage into superior epigastric and musculophrenic branches.

If they are big enough you may see when pain starts and how long it usually stays and them on ultrasound buy reminyl 4 mg fast delivery medicine 3x a day. They are usually cystic with there are only few cycles where they won’t experi- decreased or absent echogenicity and can resemble ence pain order reminyl 8 mg with visa medicine 3605. Thus, for a successful treatment and ovarian cysts or hydrosalpinx. See • Always have your NSAIDs in stock and in reach Chapter 17 on STI for description of ultrasound when you are near your period. Don’t wait until the pain is Urine pregnancy test/urinalysis very strong because this is too late. Every patient with new pelvic pain should have a • Always take your NSAIDs as long as the pain urine pregnancy test (UPT) to exclude ectopic usually stays. It is important to prescribe drugs for 3 months and Do urine analysis to exclude chronic urinary tract then see the patient again to assess together with infection and schistosomiasis in endemic areas. If not, change to another NSAID or add an oral contraceptive if no Erythrocyte sedimentation rate/white blood cell count pregnancy is planned. These can help confirm or exclude an infectious cause of pelvic pain such as tubo-ovarian masses or Non-steroidal anti-inflammatory drugs for PID. The therapy for primary dysmenorrhea is very • Ibuprofen tablets 400mg t. You can also pre- stop or decrease once the underlying cause is scribe the OCP non-cyclic: the woman will not treated. You will find the respective therapies for get a period and will not have dysmenorrhea. In cases where no underlying rhea any non-steroidal anti-inflammatory drug pathology is found in a woman in later reproduc- (NSAID: aspirin, diclofenac, ibuprofen, indo- tive life, treat with NSAIDs as for primary dysmen- metacin) is very effective (level I evidence). If there is no actual desire for pregnancy There is no study showing the superiority of one you can give COC continuous (see Chapter 6) 82 Painful Menstrual Period: Dysmenorrhea which will reduce the number of painful periods. An alternative that becomes increasingly REFERENCES available in resource-poor settings as well is the 1. WHO systematic review levonorgestrel intrauterine device called Mirena. BMC Public Health 2006;6:177 after a year and before the prevalence of dysmenor- 2. Prevalence and impact of dysmenorrhea on Hispanic female adoles- rhea is reduced. Arch Pediat Adolesc Med 2000;154:1226–9 contraceptives can be used in primary dysmenor- 3. Oral rhea as well, but a regular contraceptive pill is pre- contraceptive pill for primary dysmenorrhea. Database Syst Rev 2009;4:CD002120 Don’t forget that dysmenorrhea can have psychosomatic causes as well and assess the patient Further reading for this or refer to a competent provider in your Marjoribanks J, Proctor M, Farquhar C, Derks RS. It is worthwhile talking to the psychiatric steroidal anti-inflammatory drugs for dysmenorrhea. Ameh INTRODUCTION accounted for about 13% of maternal deaths (MD) (47,000 MD per year). There is also a huge dis- Several definitions of abortion are found in the parity in the ratio of maternal deaths attributable to literature but it is widely accepted that abortion is unsafe abortion per 100,000 live births in devel- the loss of a pregnancy before the period of via- 1,2 oped countries compared to developing countries: bility. This period of viability will depend on the 5 1 vs 40/100,000. Less developed regions of the resources available; in many resource-poor settings world have the greatest risk of morbidity and mor- most of the babies delivered at gestational age of 28 tality from unsafe abortion, the least proportion of weeks or more may survive. In the better resourced skilled health personnel, the lowest contraceptive parts of the world, fetuses weighing 500g or more prevalence rates and, largely, have restrictive abor- or a gestational age above 24 weeks can survive 3 tion laws. Deaths from unsafe abortion are entirely pre- The term abortion often has emotional conno- ventable through the use of contraceptives, use of tations for women and their families dealing with safe termination services especially when contra- loss of a pregnancy. Using the term ‘abortion’ is ceptives fail or for pregnancies resulting from even more challenging in countries where termina- gender-based violence (sexual violence, rape etc.