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Maypantibody response to live-virus vaccine andqrisk of antagonistic reactions (do not administer concurrently). Interactions Drug-Drug: Concurrent use with anakinraqrisk of Implementation Do not confuse Enbrel with Levbid. Administer a tuberculin skin check previous to administra- Route/Dosage Subcut (Adults): Adult rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis- 50 mg once weekly; grownup plaque psoriasis- 50 mg twice weekly for three mo, then 50 mg as quickly as weekly, may also be given as 25� 50 mg once weekly as an initial dose. Subcut: Prepare injection with single dose pre-filled syringe or multidose vial for reconstitution. For multidose vial, reconstitute with 1 mL of the bacteriostatic sterile water equipped by manufacturer for a concentration of 25 mg/mL. If the vial is used for multiple doses, use a 25-gauge needle for reconstituting and withdrawing solution and apply "Mixing Date" sticker with date of reconstitution entered. Administer as soon as attainable after reconstitution; steady as a lot as 6 hr if refrigerated. Solution and pre-filled syringes are stable if refrigerated and used within 14 days. Syringe Incompatibility: Do not combine with other solutions or dilute with other diluents. Indications Active tuberculosis or other mycobacterial diseases (with at least one other drug). Metabolism and Excretion: 50% metabolized by the liver, 50% eradicated unchanged by the kidneys. Distribution: Widely distributed; crosses blood- Patient/Family Teaching Instruct patient on self-administration method, storage, and disposal of kit. First injection should be administered beneath the supervision of health care skilled. Parents should be suggested that children should full immunizations to date earlier than initiation of etanercept. Patients with significant exposure to varicella virus (chickenpox) should temporarily discontinue therapy and varicella immune globulin ought to be thought-about. Instruct affected person to notify health care skilled if higher respiratory or different infections occur. Interactions Drug-Drug: Neurotoxicity may beqwith different neuRoute/Dosage Symptoms might return inside 1 mo of discontinuation of therapy. E be carried out before and periodically throughout remedy to detect possible resistance. Advise affected person to report blurring of vision, constriction of visual fields, or changes in color notion immediately. Visual impairment, if not identified early, might result in permanent sight impairment. Frequently causes elevated uric acid concentrations, which can precipitate an attack of gout. Potential Nursing Diagnoses Risk for infection (Indications) Disturbed sensory perception (Side Effects) Implementation Ethambutol is given as a single day by day dose and should be taken on the same time each day. Usually administered concurrently with different antitubercular medications to prevent growth of bacterial resistance. Do not discontinue with out consulting well being care skilled, despite the precise fact that symptoms could disappear. Instruct patient to notify well being care professional if no enchancment is seen in 2� three wk. Health care professional must also be notified if unexpected weight achieve or decreased urine output happens. Emphasize the significance of routine exams to evaluate progress and ophthalmic examinations if signs of optic neuritis happen. Metabolism and Excretion: Mostly metabolized by the liver; 1% excreted unchanged in urine. Drug-Natural Products:qrisk of bleeding with arnica, chamomile, clove, dong quai, fever few, garlic, ginko, and Panax ginseng. Osteoarthritis/Rheumatoid Arthritis: Assess ache and vary of motion earlier than and 1� 2 hr after administration. Pain: Assess location, duration, and depth of the ache earlier than and 60 min after administration.

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Function: It stabilizes the cervix at the level of interspinous diameter together with the other ligaments. Pelvic cellular tissues: the endopelvic fascia encompass connective tissues and easy muscle tissue. The blood vessels and nerves supplying the uterus, bladder and vagina cross through it from the lateral pelvic wall. As they cross, the pelvic cellular tissues condense surrounding them and provides good direct assist to the viscera. This hammock-like arrangement of condensed pelvic mobile tissues is the cardinal support of the uterus. The support is principally given by the pelvic floor muscular tissues (levator ani), endopelvic fascia, levator plate, perineal physique and the urogenital diaphragm (see p. Any raised intra-abdominal strain is transmitted solely to the anterior vaginal wall which is apposed to the posterior vaginal wall. Pelvic mobile tissue: the vagina is ensheathed by strong condensation of pelvic cellular tissue called endopelvic fascia. Traced under, this fascia types the posterior urethral ligament, which is anchored to the pubic bones giving sturdy assist to the urethra. The levator ani muscles with its fascial coverings: this muscle is slug like a hammock around the midline pelvic effluents (urethra, vagina and the anal canal). This strong, strong and fatigue-resistant striated muscle guards the hiatus urogenitalis. It helps the pelvic viscera and counteracts the downward thrust of increased intraabdominal strain. These pubovisceral fibers of the levator ani muscles squeeze the rectum, vagina and urethra and keep them closed by compressing in opposition to the pubic bone. Some of the fibers lengthen anteriorly encircling the anorectal junction and are inserted into the perineal body. The horizontal position of this shelf is maintained by the anterior traction of the fibers of pubococcygeus and the iliococcygeus muscle tissue. Due to its horizontal place, the levator plate can prevent the prolapse of genital organs. This is due to the lack of tone of the levator ani muscle tissue following harm, overstretching (childbirth process) or attenuation (menopause). Clinically, the levator plate is assessed by palpating the perineum between two fingers contained in the introitus and the thumb outside. Perineal physique is a strong pyramidal construction at the central point of the perineum. The clinical elements are grouped as: Predisposing Aggravating Predisposing Factors Acquired Congenital Acquired: Vaginal delivery with consequent damage to the supporting constructions is the only most important acquired predisposing factor in producing prolapse. Acquired Trauma of vaginal delivery causing harm (tear or break) to: x Ligaments x Endopelvic fascia x Levator muscle (myopathy) x Perineal body x Nerve (pudendal) and muscle injury due to repeated youngster start B. This might seem independently or usually along with cystocele and is known as cystourethrocele. Posterior Wall x Relaxed perineum: Torn perineal body produces gaping introitus with bulge of the decrease a part of the posterior vaginal wall. Vault Prolapse Congenital: Congenital weak spot of the supporting buildings is answerable for nulliparous prolapse or prolapse following a simple vaginal delivery. One must be on the look out for an occult spina bifida and related neurological abnormalities. Undetected enterocele throughout preliminary operation or insufficient main restore normally results in secondary vault prolapse Table sixteen. Uterine Prolapse There are two types: x Uterovaginal prolapse is the prolapse of the uterus, cervix, and upper vagina. Cystocele occurs first followed by traction effect on the cervix causing retroversion of the uterus.

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They migrate from the yolk sac to the genital ridge alongside the dorsal mesentery by ameboid motion between 20 and 30 days. The germ cells undergo a quantity of rapid mitotic divisions and differentiate into oogonia. The mitotic division steadily ceases and the bulk enter into the prophase of the first meiotic division and are known as major oocytes. These are surrounded by flat cells (granulosa cells) and are called primordial follicles. Around the time of arrival of germ cells, the coelomic epithelium of the genital ridge proliferates. The irregular cords of cells (primitive intercourse cords) invaginate the underlying mesenchyme. These cords of cells encompass the primordial germ cells and still have connection the surface turns into thicker and continues to proliferate extensively. It sends down secondary cords of cells into the mesenchyme (cortical cords), but unlike testis, maintains reference to the surface epithelium. In the fourth month, these cords split into clusters of cells, which encompass the germ cells. The germ cells would be the future oogonia and the epithelial cells would be the future granulosa cells. The stromal mesenchymal cells additionally surround the follicular construction to type the longer term theca cells. By twenty eighth week, variety of these follicles are exposed to maternal gonadotropin and undergo various levels of maturation (little in need of antrum formation) and atresia. From the decrease pole of the ovary, genital ligament (gubernaculum) is shaped, which is attached to the genital swelling (labial). The genital ligament will get an intermediate attachment because it comes near M�llerian ducts (angle of the growing uterus). The half between the ovary and the M�llerian attachment is the ovarian ligament and the part between the cornu of the uterus to the top is the spherical ligament. Clitoris is developed from the genital tubercle, labia minora from the genital folds and labia majora from the genital swellings. The cortex and the masking epithelium are developed from the coelomic epithelium and the medulla from the mesenchyme. The germ cells are endodermal in origin and migrate from the yolk sac to the genital ridge. The bipotential gonad develops into an ovary about two weeks later than the testicular growth. The a half of the gubernaculum (genital ligament) between the decrease pole of the ovary and the M�llerian attachment is the ovarian ligament. The part between the cornu of the uterus (M�llerian attachment) to the end (external genitalia) is the spherical ligament. The paramesonephric duct in female differentiates into fallopian tube, uterus, and cervix. The mesonephric duct in male gives rise to epididymis, vas deferens and seminal vesicles. The sinovaginal bulbs, which grow out from the posterior facet of the urogenital sinus, differentiates into vagina. Urinary bladder develops from the upper vesicourethral part of the urogenital sinus except the trigone. Adult kidney develops from the metanephros, and its amassing system (ureter and calyceal system) from the ureteric bud of the mesonephric duct. Major anatomic defect of the genital tract is often related to urinary tract abnormality (40%), skeletal malformation (12%), and regular gonadal perform. Dyspareunia will be the first complaint, or it could be detected during investigation of infertility. It is due to failure of disintegration of the central cells of the M�llerian eminence that tasks into the urogenital sinus (see p. The existence is nearly all the time unnoticed until the woman attains the age of 14�16 years. As the uterus is functioning usually, the menstrual blood is pent up inside the vagina behind the hymen (cryptomenorrhea). Depending upon the quantity of blood so accumulated, it first distends the vagina (hematocolpos).

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Derm: photosensitivity, rashes, sweating, pseudoporphyria (12% incidence in kids with juvenile rheumatoid arthritis- discontinue remedy if this occurs). In combination with: pseudoephedrine (Aleve-D Sinus and Cold), sumatriptan (Treximet). Potential Nursing Diagnoses Acute pain (Indications) Chronic ache (Indications) Impaired physical mobility (Indications) tions without consulting well being care skilled. Implementation Administration in higher than recommended doses Evaluation/Desired Outcomes Relief of pain. Use lowest efficient dose for the shortest length potential to reduce cardiac risks. Therapeutic Effects: Cranial vessel vasoconstriction with resultant lower in migraine headache. Patient/Family Teaching Advise patient to take this treatment with a full glass of water and to remain in an upright place for 15� 30 min after administration. Advise affected person to avoid driving or other activities requiring alertness until response to the treatment is understood. Exercise Extreme Caution in: Cardiovascular threat components (hypertension, hypercholesterolemia, cigarette smoking, weight problems, diabetes, robust household history, menopausal women or men forty yr); use only if cardiovascular status has been evaluated and determined to be safe and 1st dose is run under supervision. Contraindications/Precautions Contraindicated in: Hypersensitivity; Ischemic tion and associated symptoms (photophobia, phonophobia, nausea, vomiting) during migraine assault. Avoid concurrent use (within 24 hr of every other) with ergot-containing medication (dihydroergotamine) could result in prolonged vasospastic reactions. It is supposed to be used for reduction of migraine assaults however to not forestall or cut back the variety of assaults. Instruct affected person to administer naratriptan as quickly as symptoms of a migraine attack appear, however it might be administered any time throughout an assault. Advise affected person that lying down in a darkened room following naratriptan administration may further assist relieve headache. Advise affected person that overuse (use greater than 10 days/ month) might result in exacerbation of headache (migraine-like daily headaches, or as a marked improve in frequency of migraine attacks). May require gradual withdrawal of naratriptan and remedy of signs (transient worsening of headache). Advise patient to notify well being care professional previous to next dose of naratriptan if ache or tightness in the chest occurs during use. Instruct affected person to not take further naratriptan if no response is seen with preliminary dose with out consulting health care professional. Caution affected person not to use naratriptan if pregnancy is deliberate or suspected or if breast feeding. Contraindications/Precautions Contraindicated in: Hypersensitivity; Severe brady- N Indications Hypertension (alone and with other antihypertensives). Action Blocks stimulation of beta adrenergic receptor sites; selective for beta1 (myocardial) receptors in most sufferers. In some sufferers (poor metabolizers, greater blood levels may result in some beta2 [pulmonary, vascular, uterine] adrenergic) blockade. If used concurrently with clonidine, nebivolol ought to be tapered and discontinued a number of days previous to gradual withdrawal of clonidine. When discontinuation is planned, observe patient carefully and advise to reduce physical exercise. If angina worsens or acute coronary insufficiency develops, reinstitute nebivolol promptly, at least temporarily. Reinforce the necessity to proceed further therapies for hypertension (weight loss, sodium restriction, stress reduction, regular exercise, moderation of alcohol consumption, and smoking cessation). Patients on antihypertensive therapy also needs to avoid extreme amounts of espresso, tea, and cola. Diabetics should carefully monitor blood sugar, especially if weakness, malaise, irritability, or fatigue happens.

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Patient/Family Teaching Inform affected person and household of reasons for administra- tion. Increases bladder capability by stress-free detusor easy muscle during storage section of bladder fill-void cycle. Metabolism and Excretion: Extensively metabolized, 6% excreted unchanged in urine (25 mg dose), the rest excreted in urine and feces as metabolites. Advise patient to learn Patient Information sheet prior to starting and with each Rx refill in case of modifications. Advise patient to notify health care professional if issue emptying bladder happens. Mayqlevels and danger of toxicity with digoxin; use lowest efficient degree of digoxin/monitor serum levels). Monitor for indicators and signs of angioedema Action Potentiates the consequences of norepinephrine and serotonin. Therapeutic Effects: Antidepressant motion, which can develop solely after a quantity of weeks. Potential Nursing Diagnoses Impaired urinary elimination (Indications) Urinary retention (Indications) Pharmacokinetics Absorption: Well absorbed however quickly metabolized, resulting in 50% bioavailability. If a dose is missed, omit dose and start taking next day; lized by the liver (P450 2D6, 1A2 and 3A enzymes involved); metabolites excreted in urine (75%) and feces (15%). Contraindications/Precautions Contraindicated in: Hypersensitivity; Concurrent zepine, rifampin, or rifabutin mayplevels; may have toqmirtazapine dose. Ketoconazole, cimetidine, clarithromycin, erythromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, or saquinavir mayqlevels. Phenobarbital, phenytoin, carbama- Interactions Drug-Drug: May trigger hypertension, seizures, and regularly. For overweight/obese people, acquire fasting blood glucose and cholesterol levels. Monitor for seizure activity in sufferers with a historical past of seizures or alcohol abuse. Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness). Discontinue mirtazapine and notify well being care professional immediately if these signs happen. Potential Nursing Diagnoses Ineffective coping (Indications) Anxiety (Indications) misoprostol 857 Imbalanced nutrition: danger for greater than body requirements (Side Effects) sional before taking different drugs, particularly St. Emphasize the significance of follow-up exam to monitor effectiveness and unwanted aspect effects. Implementation May be given as a single dose at bedtime to reduce extreme drowsiness or dizziness. Evaluation/Desired Outcomes Patient/Family Teaching Instruct affected person to take mirtazapine as directed. Take missed doses as soon as remembered; if virtually time for subsequent dose, skip missed dose and return to regular schedule. Encourage patient and family to be alert for emergence of tension, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, mania, worsening of depression and suicidal ideation, especially during early antidepressant therapy. Advise patient to notify well being care professional if dry mouth, urinary retention, or constipation occurs. Therapeutic results could additionally be seen within 1 wk, though several wk are often necessary before improvement is noticed. Action Acts as a prostaglandin analogue, lowering gastric acid secretion (antisecretory effect) and growing the production of protecting mucus (cytoprotective effect). Metabolism and Excretion: Undergoes some metabolism and is then excreted by the kidneys. Pharmacokinetics Absorption: Well absorbed following oral adminis- Canadian drug name. Pregnancy status must be determined earlier than initiating therapy; Pedi: Safety not established.

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Tapering off medicine should be attempted each 3� 6 mo in decrements of 50 mg every 2� 4 wk. Decrease in serum and urine paraprotein measurements in sufferers with multiple myeloma. Lab Test Considerations: May interfere with sure methods of testing serum theophylline, uric acid, and urobilinogen concentrations. Potential Nursing Diagnoses Imbalanced vitamin: lower than body requirements (Indications) hol intolerance or bisulfite hypersensitivity (elixir only). Contraindications/Precautions Contraindicated in: Hypersensitivity; Known alco- Implementation Do not confuse thiamine with Thalomid (thalido- mide). Y-Site Compatibility: alfentanil, amikacin, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, cefazolin, cefonocid, cefotaxime, cefotetan, cefoxitin, ceftriaxone, cefuroxime, chlorpromazine, clindamycin, cyanocobalamin, cyclosporine, dexamethasone, digoxin, diphenhydramine, dobutamine, dopamine, doxycycline, enalaprilat, ephedrine, epinephrine, erythromycin, esmolol, famotidine, fentanyl, gentamicin, glycopyrrolate, heparin, insulin, isoproterenol, labetalol, lidocaine, magnesium sulfate, mannitol, meperidine, metaraminol, methoxamine, methyldopate, metoclopramide, metoprolol, morphine, multivitamins, nafcillin, nalbuphine, naloxone, nitroglycerin, nitroprusside, norepinephrine, oxacillin, oxytocin, papaverine, penicillin G, pentamidine, pentazocine, phentolamine, phenylephrine, phytonadione, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, protamine, pyridoxime, ranitidine, streptokinase, succinylcholine, sufentanil, theophylline, tobramycin, tolazoline, trimetaphan, vancomycin, vasopressin, verapamil. Y-Site Incompatibility: aminophylline, amphotericin B colloidal, azathioprine, ceftazidime, chloramphenicol, dantrolene, diazepam, diazoxide, folic acid, furosemide, ganciclovir, hydrocortisone, imipenem/cilastatin, indomethacin, methylprednisolone, pentobarbital, phenobarbital, phenytoin, sodium bicarbonate, trimethoprim/sulfamethoxazole. Additive Incompatibility: Solutions with impartial or alkaline pH, such as carbonates, bicarbonates, citrates, and acetates. Confusion and psychosis could take longer to reply and should persist if nerve injury has occurred. Action Convert plasminogen to plasmin, which is then capable of degrade fibrin present in clots. Streptokinase combines with plasminogen to form activator complexes, which then converts plasminogen to plasmin. Patient/Family Teaching Encourage patient to comply with dietary recom- mendations of well being care skilled. Explain that the best supply of vitamins is a well-balanced food regimen with meals from the four fundamental food teams. Teach affected person that meals high in thiamine include cereals (whole grain and enriched), meats (especially pork), and fresh vegetables; loss is variable during cooking. The effectiveness of megadoses of nutritional vitamins for therapy of various medical situations is unproved and may trigger unwanted effects. Evaluation/Desired Outcomes Prevention of or decrease within the indicators and signs of vitamin B deficiency. Decrease within the signs of neuritis, ocular indicators, ataxia, edema, and coronary heart failure may be seen within coronary administration or administration into occluded catheters or cannulae has a more localized effect. Streptokinase- Rapidly cleared from circulation by antibodies and different unknown mechanism. Half-life: Alteplase- 35 min; reteplase- 13� sixteen min; streptokinase- initially 18 min (due to clearance by antibodies), then eighty three min; Tenecteplase- 20� 24 min (initial phase), 90� one hundred thirty min (terminal phase). Effects may be pby antifibrinolytic agents, together with aminocaproic acid or tranexamic acid. Drug-Natural Products:qanticoagulant impact and bleeding risk with anise, arnica, chamomile, clove, dong quai, fenugreek, feverfew, garlic, ginger, ginkgo, Panax ginseng, licorice, and others. Exercise Extreme Caution in: Patients receiving concurrent anticoagulant therapy (qrisk of intracranial bleeding). Intracoronary (Adults): 20,000 unit bolus adopted by 2000� 4000 units/min infusion for 30� ninety min. Streptokinase may be much less efficient if administered between 5 days and 6 mo of a streptococcal an infection. Altered sensorium or neurologic changes could additionally be indicative of intracranial bleeding. Radionuclide myocardial scanning and/or coronary angiography could also be ordered 7� 10 days after remedy to monitor effectiveness of therapy. Deep Vein Thrombosis/Acute Arterial Thrombosis: Observe extremities and palpate pulses of affected extremities every hour. Cannula/Catheter Occlusion: Monitor capacity to aspirate blood as indicator of patency. Bleeding time may be assessed before remedy if patient has obtained platelet inhibitors. Obtain sort and crossmatch and have blood out there at all times in case of hemorrhage.

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Uterus is thus maintained anteflexed and the vagina is suspended over the levator plate. It is attached on the cornu of the uterus beneath and in front of the fallopian tube. After traversing via the inguinal canal, it fuses with the subcutaneous tissue of the anterior third of the labium majus. It corresponds developmentally to the gubernaculum testis and is morphologically continuous with the ovarian ligament. The lymphatics from the physique of the uterus pass along it to reach the inguinal group of nodes. It is analogous to the processus vaginalis which precedes to descent of the testis. Insertion: Anterolateral supravaginal cervix and blends with the pericervical ring of endopelvic fascia and the cardinal ligaments. They serve primarily as vascular conduit and supply less cervical stabilization drive. Vesicovaginal septum: It is a fibroelastic connective tissue with some clean muscle fibers. Arcus tendinous fascia (white line) and centrally to the pubocervical ring, mixing with the pubocervical and cardinal ligaments, and pelvic visceral fascia. Function: It helps the posterior vaginal wall, stabilizes the rectum and the perineum. Extension: Anteriorly, it lies between the bottom of the bladder and the anterior cervix. Paravagial defect may be due to: � Complete detachment of pubocervical fascia from the arcus tendineus fascia. One part stays attachment to the pelvic aspect wall while the opposite half sags down with the attached pubocervical fascia. The length of the anterior vaginal wall is 7 cm and that of posterior wall is 9 cm. Isthmus is bounded above by the anatomical inner os and beneath by the histological inside os. Fallopian tube has obtained four parts-interstitial (1 mm diameter), isthmus, ampullary (fertilization takes place), and infundibulum (6 mm diameter). The cortex is studded with follicular constructions and the medulla incorporates hilus cells which are homologous to the interstitial cells of the testes. Mucous coat in the upper two-thirds is lined by stratified transitional epithelium and in the distal one third by stratified squamous epithelium. It is comparatively constricted (i) the place it crosses the brim, (ii) where crossed by the uterine artery, and (iii) in the intravesical half. The ureter is prone to be damaged during hysterectomy on the infundibulopelvic ligament, by the side of the cervix, on the vaginal angle and during posterior peritonization. The ureter in the pelvis might be identified by (a) seeing peristalsis after simulation with a surgical instrument and (b) by the plexus of longitudinal blood vessels. Superficial perineal pouch is shaped by the deep layer of the superficial perineal fascia and inferior layer of the urogenital diaphragm. The deep perineal pouch is shaped by the inferior and superior layer of the urogenital diaphragm. Obstetrical perineum is the fibromuscular structure, pyramidal-shaped with the bottom lined by the perineal pores and skin and located in between the vaginal and anal canal. Pelvic mobile tissues (endopelvic fascia), ligaments, perineal physique, pelvic flooring muscular tissues (levator ani), assist the pelvic organs and counteracts the downward thrust of elevated intra-abdominal pressure. Broad ligament has got four parts-infundibulopelvic ligament, mesovarium, mesosalpinx and mesometrium. Broad ligament accommodates Fallopian tube, round ligament, ovarian ligament, parametrium, utero-ovarian anastomotic vessels, nerves, lymphatics of the uterus, tubes and ovaries and vestigial structures-duct of Gartner, epoophoron, and paroophoron. One finish is connected to cornu of the uterus and the other finish terminates in the anterior third of the labium majus. Internal Iliac Artery Internal iliac artery is considered one of the bifurcations of the common iliac artery.