Preeclampsia prevention
Preeclampsia is defined as a new-onset hypertension along with other features like proteinuria &/or end-organ damage at >20 weeks of gestation.
Patients with the following histories are at high risk for preeclampsia:
– Those with prior history of preeclampsia
– Those with chronic kidney disease
– Those with chronic hypertension
– Those with diabetes mellitus
– Multiple gestation
– Autoimmune disease
Patients belonging in the following criteria are at moderate risk for preeclampsia:
– Obesity
– Advanced maternal age
– Nulliparity

Preeclampsia is considered as the leading cause for maternal and fetal morbidity and mortality. This is due to its increased risk for complications such as stroke, placental abruption and disseminated intravascular coagulation. It is most likely caused due to abnormal vasoconstriction and increased platelet aggregation, which thereby results in placental infarction and ischemia. The condition can be effectively prevented by the administration of low-doses of aspirin at 12 weeks of gestation.

Patients with predisposing factors, such as chronic kidney disease, chronic hypertension and a history of preeclampsia, particularly with severe features or at <37 weeks gestation as in this patient, are at higher risk for developing preeclampsia.
In high risk patients, the only therapy proven to decrease the risk of preeclampsia is a daily administration of low-dose aspirin, as it inhibits platelet aggregation and helps in preventing placental ischemia. Treatment is initiated at 12 – 28 weeks of gestation, optimally before 16 weeks and is continued till delivery.

Betamethasone is a drug used to accelerate fetal lung maturity in patients who are prone to imminent risk of preterm delivery before 37 weeks of gestation. In this case, if the patient develops pre-eclampsia requiring an urgent preterm delivery betamethasone will be indicated.

High-doses (4 mg) of folic acid is indicated in patients with high risk for a fetus with neural tube defects, as in those who have a history of any prior pregnancies affected or those patients who use any folate antagonist medications. In the given case patient is at average risk and requires only a regular dose of 0.4 mg which is found in most prenatal vitamins.

Intramuscular hydroxyprogesterone is indicated in pregnant patients with prior spontaneous preterm delivery due to preterm prelabor rupture of membranes, preterm labor, etc to decrease the possible risk for any recurrence. In patients who underwent preterm delivery due to other indications like preeclampsia with severe features, fetal growth restriction, etc it is not indicated.

Vaginal progesterone is administered to decrease the risk of preterm delivery in patients diagnosed with a shortened cervix, which is usually identified incidentally on anatomy ultrasound scan done between 16 and 24 weeks of gestation. This patient is currently at her 14 weeks, so this is not advisable.

Patients at high risk for pre-eclampsia, like those with preeclampsia in a prior pregnancy, are advised to start taking a daily low-dose aspirin as prophylaxis for prevention of pre-eclampsia during pregnancy.

The following hormones are excreted from the anterior pituitary gland: TSH, GN, ACTH, LH, FSH, MSH, PRL.
Human chorionic gonadotropin (hCG, or human chorionic gonadotrophin) is a placental hormone secreted by syncitiotrophoblasts during the second week of gestation.

P wave = Atrial depolarisation
QRS complex = Ventricular depolarisation
T wave = Ventricular repolarisation
U wave = repolarisation of the interventricular septum

In this case, induction of labour at 37 weeks of gestation was necessary due to the absence of spontaneous of labour 24 hours after rupture of membranes. High doses of Syntocin and large volume of fluids may be required particularly when induction is done before term.

Syntocin infusion can lead to uterine hypertonus and tetany which can result in fetal distress at any dosage. This is a common reason to decrease or stop the infusion and an indication for Caesarean delivery due to fetal distress

Uterine rupture can occur as a result of Syntocin infusion especially when the accompanying fluids do not contain electrolytes, which puts the patient at risk for water intoxication.

Maternal hypotension results from Syntocin infusion, not hypertension.

Fetal production of immunoglobulin begins early on, at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity, is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth.

Circulation in the foetus: 1. Deoxygenated fetal blood is conducted to the placenta via the two umbilical arteries. The umbilical arteries arise from the internal iliac arteries.
2. Gas exchange occurs in placenta.
3. Oxygenated blood from the placenta passes through the single umbilical vein and enters the inferior vena cava (IVC).
4. About 50% of the blood in the IVC passes through the liver and the rest bypasses the liver via the ductus venosus. The IVC also drains blood returning from the lower trunk and extremities.
5. On reaching the heart, blood is effectively divided into two streams by the edge of the interatrial septum (crista dividens) (1) a larger stream is shunted to the left atrium through the foramen ovale (lying between IVC and left atrium) (2) the other stream passes into right atrium where it is joined by blood from SVC which is blood returning from the myocardium and upper parts of body. This stream therefore has a lower partial pressure of oxygen.
6. Because of the large pulmonary vascular resistance and the presence of the ductus arteriosus most of the right ventricular output passes into the aorta at a point distal to the origin of the arteries to the head and upper extremities. The diameter of the ductus arteriosus is similar to the descending aorta. The patency of the ductus arteriosus is maintained by the low oxygen tension and the vasodilating effects of prostaglandin E2;
7. Blood flowing through the foramen ovale and into left atrium passes into the left ventricle where it is ejected into the ascending aorta. This relatively oxygen rich blood passes predominantly to the head and upper extremities.

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

An LSIL Pap test shows mild cellular changes. The risk of a high-grade cervical precancer or cancer after an LSIL Pap test is as high as 19 percent.

As with an ASC-US Pap test, an LSIL Pap test is evaluated differently depending upon age. For women ages 25 or older, follow-up depends upon the results of human papillomavirus (HPV) testing:

– Women who test positive for HPV or who have not been tested for HPV should have colposcopy.
– Women who test negative for HPV can be followed up with a Pap test and HPV test in one year.

Referral to an oncologist is not necessary since there is no established diagnosis of malignancy. All other options are unacceptable.

Rubella typically has an incubation period of around 14 days. Rage 12-23 days

Shortly after the Morula enters into the uterus, approximately on the 4th day after fertilization a fluid filled cystic cavity appears in the morula and transforms the morula into a blastocyst.

This patient should be advised to use both an OCP and a condom. The combined oestrogen/progestogen contraceptive pill (COCP) has been found to be very effective. However, she should be made aware that it would not provide any protection from any sexually transmitted diseases so she might still be at risk of developing a STD, depending on her sexual partner preferences. To ensure protection from STDs, she should be advised to use both condoms as well as the combined OCP. An IUCD (intrauterine contraceptive device) would not be preferable if she has multiple sexual partners (high risk of STDs). If she has been screened for STDs, does not actively have an STD and has only one sexual partner then IUCD is a possible option. Some issues that may arise with spermicide use could be related to compliance. This also applies to using condoms alone. These two options are less reliable as compared to COCP.

Fetal lie refers to the relationship between the long axis of the foetus relative to the long axis of the mother. If the foetus and maternal column are parallel (on the same long axis), the lie is termed vertical or longitudinal lie.

Fetal presentation means, the part of the foetus which is overlying the maternal pelvic inlet.

Position is the positioning of the body of a prenatal foetus in the uterus. It will change as the foetus develops. This is a description of the relation of the presenting part of the foetus to the maternal pelvis. In the case of a longitudinal lie with a vertex presentation, the occiput of the fetal calvarium is the landmark used to describe the position. When the occiput is facing the maternal pubic symphysis, the position is termed direct occiput anterior.

Fetal attitude is defined as the relation of the various parts of the foetus to each other. In the normal attitude, the foetus is in universal flexion. The anatomic explanation for this posture is that it enables the foetus to occupy the least amount of space in the intrauterine cavity. The fetal attitude is extremely difficult, if not impossible, to assess without the help of an ultrasound examination.

Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma’s) sometimes called myoma’s.

A Bicornuate uterus (heart shaped) is the result of abnormal fusion and reabsorption of the paramesonephric ducts during embryogenesis. Mullerian agenesis typically results in failure to form a uterus. Mullerian duct fusion abnormalities can cause a bicornuate malformation. PKD-1 gene abnormalities are associated with PCOS. Crossed fused ectopia result in Horseshoe kidney.

Chorion villus sampling is an invasive procedure which aims to collect the rapidly dividing cells in the placenta. It is used for numerous reasons including detection of early pregnancy, viability of the foetus, singleton pregnancy, confirm gestation age and for prenatal diagnosis of the fetal chromosomal abnormalities including diagnosis of Down’s syndrome. However it hold a 2% chance of miscarriage during the procedure. Nuchal thickness and imaging are part of the combined test that must have been performed before.

1 in 150 is the cut off. Where pre-natal screening shows a risk of 1 in 150 or greater invasive testing is typically offered.

Although a dilatation and curettage (D&C) is frequently recommended as part of a woman’s menorrhagia examination.
D&C is not indicated in a woman who had a normal hysteroscopy and laparoscopy only two years ago, and who experienced comparable symptoms when not taking the OCP in the past, especially after the age of 40.
The Filshie clips should not be removed because they will not improve the symptoms.

Although an endometrial ablation or possibly a hysterectomy may be required in the future to address the symptoms, the first line of treatment should be a nonsteroidal anti-inflammatory drug (NSAID), which will reduce the loss in up to half of the women treated.

Postmenopausal haemorrhage has started in this patient. Menopause is defined as the permanent cessation of menstruation and fertility that occurs 12 months after the previous menstrual period.

Atrophic vaginitis caused by oestrogen insufficiency is the most likely reason for this woman’s postmenopausal haemorrhage. It can also induce vaginal dryness and soreness during sexual intercourse.

Endometrial hyperplasia is unlikely to develop without hormone replacement therapy or oestrogen stimulation of the endometrium.

Similarly, endometrial cancer is a less likely cause of this patient’s post-menopausal bleeding.

A year ago, this woman received a normal cervical screening test. Cervical cancer is extremely unlikely to occur. After 12 months of no oestrogen, it’s also unlikely that you’ll have any irregular periods.

Up to 20% of women have been found to have Group B streptococcus (GBS). GBS is considered a normal flora of the gastrointestinal tract. GBS infection is generally asymptomatic although some women might end up having a UTI. Infants born to mothers who are colonised with GBS during labour are at a higher risk of developing early-onset GBS infection. If a pregnant woman develops a UTI due to GBS, it is suggestive of significant GBS colonisation. IV penicillin would be the drug of choice and is to be administered to the mother during labour which would provide sufficient protection for the foetus and would be effective enough. If penicillin is unavailable, ampicillin is a reasonable alternative. If a patient has penicillin allergy, vancomycin can be used. If not for penicillin, roughly 50% of babies delivered vaginally to women who are GBS positive would be colonised with the organism and out of this percentage, 1-2% can go on to develop a severe infection such as septicaemia and meningitis which could often be fatal.

IM penicillin can be administered to the newborn immediately post-delivery would be an effective prophylaxis in most cases but one should not wait until signs of infection are present to give the injection. Many newborns would still have an immature immune system which could cause some to die. Hence, it is more suitable to treat all women who tested positive during labour and the newborn as well if any signs of infection do appear. The majority of babies don’t need antibiotic treatment if their mother has been treated.

Sheehan syndrome is the pregnancy related infarction of the pituitary gland. During pregnancy the gland doubles in size but the blood supply does not increase significantly and during delivery due to the loss of blood it principates infarction. This results in fatigue, poor lactation and loss of pubic hair.

Eisenmenger’s syndrome is one where there is communication between the systemic and pulmonary system, along with increased pulmonary vascular resistance, either to systemic level or above systemic level (right to left shunt). A would-be mother must be informed that to become pregnant would incur a 50% risk of dying. Even if she survives, fetal mortality approaches 50% as well.

– Severe symptomatic aortic stenosis has a mortality in pregnancy of about 20%. Prevention of reduction in preload is necessary in all obstructive cardiac lesions. Balloon valvuloplasty can be done in pregnancy.
– Due to the increased blood volume and cardiac output in pregnancy, mitral stenosis can lead to severe pulmonary oedema. Balloon valvuloplasty can be done in pregnancy.
– Ebstein anomaly is a malformation of the tricuspid valve- It is usually not associated with maternal mortality.
– Atrial-septal defects rarely cause complications in pregnancy, labour, or delivery.

The half life of oxytocin is 5 mins, which is why is should be started as an infusion at a low rate.

Ilioinguinal nerve injury is one of the most common nerve injuries associated with pelvic surgery.

Around 30-40% of women affected by this condition complain of difficulty in conceiving.

Obligate anaerobes are a group of bacteria that cannot survive in an oxygen-rich environment. In the body, they are usually found on mucosal membranes such as that of the lower gastrointestinal system, or the vagina. Infection with these organisms is usually suprative and causes abscesses. Examples of gram-negative anaerobes include Bacteroides, Fusobacterium and Prevotella, while gram-positive anaerobes include Actinomyces and Clostridia. Staphylococcus and Streptococcus are both gram-positive facultative anaerobes.

Cephalosporins are beta lactum drugs, like penicillin. They act by inhibiting the cross linkage of the peptidoglycan wall in bacteria.

Thyroid function in pregnancy is altered in two ways; the circulating levels of the thyroid binding proteins are increased, resulting in an increase in the total circulating levels of thyroid hormones (but a slight fall in the free component).

Signs of shoulder dystocia:
– Difficulty with delivery of the face and chin
– The head remaining tightly applied to the vulva or even retracting (turtle-neck sign)
– Failure of restitution of the fetal head
– Failure of the shoulders to descend
Upon identifying shoulder dystocia additional help should be called and McRoberts manoeuvre (flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen) should be performed first. Fundal pressure is associated with uterine rupture and should not be used.

COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.

When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.

Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.

The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.

The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.