CVS has decreased in frequency with the recent increased uptake of cell-free DNA screening. It remains the only diagnostic test available in the first trimester and allows for diagnostic analyses, including fluorescence in situ hybridization (FISH), karyotype, microarray, molecular testing, and gene sequencing. CVS is performed between 10 and 14 weeks’ gestation. CVS has been performed before 9 weeks in the past, though this has shown to increase the risk of limb deformities and, therefore, is no longer recommended.

The best time of the episiotomy is when the presenting part becomes visible during the contractions. If the episiotomy is performed at the proper time, less time will be required for the delivery. However, if its done too late, it causes excessive stretching of the pelvic floor and further potential lacerations.

Oxytocin stimulates the myoepithelial cells in the breast causing the milk production. It also helps augment contractions in labour and cause uterine involution after childbirth.

Indication for a transvaginal ultrasound during pregnancy include:
– to monitor the heartbeat of the foetus
– look at the cervix for any changes that could lead to complications such as miscarriage or premature delivery
– examine the placenta for abnormalities
– identify the source of any abnormal bleeding
– diagnose a possible miscarriage
– confirm an early pregnancy

This is an ultrasound examination that is usually carried out vaginally at 6-10 weeks of pregnancy.

The aims of this scan are to determine the number of embryos present and whether the pregnancy is progressing normally inside the uterus.

This scan is useful for women who are experiencing pain or bleeding in the pregnancy and those who have had previous miscarriages or ectopic pregnancies.

Diastolic murmurs occur in conditions such as mitral stenosis, tricuspid stenosis and even in carditis. They are always pathological during pregnancy. Systolic murmurs and left axis deviation may be normal during pregnancy due to an increase in the blood volume and load on the heart.

Fetal nutrition is dependant upon multiple factors such as maternal nutritional state, quality of maternal diet, malnutrition, anorexia nervosa, metabolic rate of the mother or whether they suffer from malabsorption syndrome or other related conditions.

The half-life of Oxytocin is approximately 5 minutes
The half-life of Misoprostol is approximately 20-40 minutes
The half-life of Ergometrine is approximately 30-120 minutes

To provide suitable advice to this couple, the candidate must be aware of the following facts:
Because the luteal phase is 14 days long, regardless of the follicular phase length, ovulation happens 14 days before the period.
As a result, ovulation in this lady might have occurred as early as day 12 or as late as day 15 of her cycle.
In the presence of adequate and normal cervical mucus, sperm survival has been demonstrated to be far longer than previously thought, with intercourse occurring up to 6 days before the known period of ovulation, resulting in pregnancy.
Intercourse should be stopped six days before the earliest ovulation in this woman (i.e. on day six).
– It is generally accepted that the ovulated egg can be fertilised for approximately 24-36 hours.
Intercourse should not be restarted for at least two days after the most recent ovulation.
This would be day 17 for this woman.
Between days 6 and 17 of the cycle, abstinence is required.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 weeks old and is replaced by adult haemoglobin by the age of 5 months post natally.

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

With the use of warfarin, strict control of the INR is compulsory. After mitral valve replacement the INR should ideally be kept between 2.5-3.5. If the Ball and Cage or the Tilting Disc is used as a prosthetic valve then the target INR is 3.5, for bi-leaflets the target INR is 3.0 and for biological valves the target INR is 2.5.

Oestrogen- and progesterone-containing oral contraceptives inhibit LH, which suppresses the FSH and LH levels, preventing follicular development and ovulation. Combined pills suppress FSH and LH throughout the cycle, inhibit endometrial proliferation, and produce a scanty cervical mucus. 

Trigeminal nerve has three divisions, the first is the ophthalmic division that does not originate from any of the pharyngeal arches, the second and third divisions, namely, the maxillary and the mandibular region develop from the first pharyngeal arch.
Pharyngeal Arches:
1st = Trigeminal V2 & V3 (CN V)
2nd = Facial (CN VII)
3rd = Glossopharyngeal (CN IX)
4th and 6th = Vagus (CN X)

CMV is the most common congenital infection causing sensorineural deafness.
10-15% of infected infants will be symptomatic at birth. A further 10-15% who are asymptomatic at birth will develop symptoms later in life. Transmission can also be via breastmilk and the incubation period for CMV is 3-12 weeks. Diagnosis of fetal CMV infection is via amniocentesis however this should not be performed for at least 6 weeks after maternal infection and not until the 21st week of gestation

Dehydroepiandrosterone is an androgen precursor produced primarily by the adrenal glands in women. The steroid hormone is produced from cholesterol at birth by the fetal adrenal glands, after which its output reduces. DHEA production picks up again from the age of 5-7 years and peaks between the ages of 20-30.

The internal anal sphincter is innervated by pelvic splanchnic nerves

Trauma is a major contributor for maternal mortality and is one of the leading causes of pregnancy-associated maternal deaths.

As a result of maternal hypotension or hypoxemia, placental abruption, uterine rupture or fetal trauma a maternal trauma can compromise the fetus also.
Patient’s bruises on the abdomen which are seatbelt marks, are indications that this woman has positioned the seat belt incorrectly over the uterus. So there is a good chance that the uterus and its contents, including the fetus, has been affected by the impact. In a pregnant woman, the correct position of seat belt is when the lap belt is placed on the hip below uterus and the sash is placed between breasts and above the uterus.

A minimum of 24-hour period monitoring is recommended for all pregnant women, apart from the routine trauma workup indicated in non-pregnant women, in case they have sustained trauma in the presence of any of the following:
– Regular uterine contractions
– Vaginal bleeding
– A non-reassuring fetal heart rate tracing
– Abdominal/uterine pain
– Significant trauma to the abdomen

Considering the bruises over her abdomen this patient should be considered as having significant abdominal trauma and must be kept under observation for a minimum of 24 hours. Such patients should not be discharged unless the clinician makes sure they do not have any complications like abruption or preterm labor.

During the first 8 weeks of pregnancy, concentrations of hCG in the blood and urine usually double every 24 hours. Levels of the hormone typically peak at around 10 weeks, decline until 16 weeks, then remain constant.

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

The T10 spinal segment provides the sympathetic nerve fibres that innervate the testes

Oxytocin can also stimulate after pains that occur 2-3 following delivery.

In this pregnant patient with an antepartum haemorrhage at 37 weeks of gestation, her clinical presentation points to a placenta previa. Her bleeding has stopped, the uterus is of the expected size and non-tender, and the fetal head is still mobile above the pelvic brim which are all findings that would be consistent with a placenta praevia. An ultrasound examination would be done to rule-out or diagnose the condition.

An Apt test on the blood is necessary to ensure that this is not fetal blood that would come from a ruptured vasa praevia. Although this diagnosis would be unlikely since the bleeding has stopped. If there was a vasa praevia, there would be fetal tachycardia or bradycardia, where a tachycardia is often seen first but then bradycardia takes over late as fetal exsanguination occurs.

In a placental abruption with concealment of blood loss, the uterus would be larger and some uterine tenderness would be found on exam.

A cervical polyp could bleed after sexual intercourse and a speculum examination would be done to exclude it. However, it would be unlikely for a cervical polyp to cause such a large amount of blood loss. A heavy show would also rarely have as heavy as a loss of 200mL.

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

The maximum dose of lidocaine with adrenaline is 7mg/kg.

Serum prolactin levels are increased during suckling. Some other conditions in which serum prolactin is increased consist of: prolactin secreting brain tumours, anti psychotic drugs and hypothyroidism. It can also be increased in pregnancy, nipple stimulation and stress.

The Vaginal artery, like the Uterine artery is typically a branch of the Internal Iliac artery. It can sometimes arise as a branch of the Uterine artery so it is important to read the question (if the stem stated it CAN arise from the Uterine artery then that would be true)

The biochemical and mechanical effects of progesterone and the enlarging uterus are responsible for some changes in lung function during pregnancy.

Progesterone increases the sensitivity of the respiratory centre to arterial carbon dioxide while also causing hyperaemia in the airway leading to nasal obstruction. As a result, minute ventilation and tidal volume increase by 50% to allow greater arterial oxygen saturation.

The enlarging uterus displaces the diaphragm upwards, and also limits the movement of the thoracic cage, thereby decreasing the functional residual capacity (FRC) and the expiratory reserve volume (ERV) by 20%.

Functional Expiratory Volume in 1 second (FEV1) and Forced Vital Capacity (FVC) remain unchanged in pregnancy.

Raised pressure with the pelvis can cause a number of nerve entrapment syndromes. This is entrapment of the lateral cutaneous nerve of the thigh (or lateral femoral cutaneous nerve) also known as Meralgia Paraesthetica. Pregnancy is a risk factor. Shingles can effect this nerve but the rash would usually present itself within 14days.

Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Approximately 30-40% of women with endometriosis will be sub fertile. About one third of women with endometriosis remain asymptomatic. When they do occur, symptoms, such as the following, typically reflect the area of involvement:
– Dysmenorrhea
– Heavy or irregular bleeding
– Pelvic pain
– Lower abdominal or back pain
– Dyspareunia
– Dyschezia (pain on defecation) – Often with cycles of diarrhoea and constipation
– Bloating, nausea, and vomiting
– Inguinal pain
– Pain on micturition and/or urinary frequency
– Pain during exercise

Pregnancy, appendicitis, ureteral colic and ruptured ectopic pregnancy all do not present with dysmenorrhea, pain on defecation and dyspareunia. Presence of a non tender, soft abdomen also rules out these conditions.

Oxytocin acts via the G protein receptors and the calcium-calmodulin complex. It activates phospholipase C which produces IP3 to further trigger the calcium-calmodulin complex increasing intracellular Ca ion release.

CA-125 is the tumour marker specific for ovarian carcinoma.

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

The most likely cause of her bleeding is an endometrial polyp formation due to the tamoxifen.

Tamoxifen is often prescribed to decrease risk of breast cancer recurrence in premenopausal women with oestrogen receptor-positive cancers.

As with any medication, it has known side effects, which include endometrial polyp formation, subendometrial oedema and, rarely, endometrial carcinoma.

A polyp or carcinoma can cause uterine bleeding, but a polyp is more likely to occur.

Routine endometrial thickness screening is not recommended in all women taking tamoxifen. However, in cases of abnormal bleeding, ultrasound assessment of endometrial thickness, hysteroscopy and curettage are indicated to assess the endometrium in more detail.

Tamoxifen is not associated with endometrial atrophy.

Endometrial metastasis from a breast cancer is rare, and tamoxifen would not usually induce follicular development in a woman who has had chemotherapy and resultant amenorrhoea.

Congenital uterine abnormalities are associated with an increased risk of spontaneous abortions, preterm delivery of the foetus, fetal growth retardation and malpresentation.

Glucagon release is inhibited by increased blood glucose, ketones, free fatty
acids, insulin, raised urea levels and somatostatin. Glucagon is produced by alpha cells of the pancreas and increases the plasma glucose level by stimulating glycogenolysis and gluconeogenesis.

It is essential to notice the important details mentioned in the case scenario. These would be the details about her menstruation, a smaller than dates uterus and an open cervix. A smaller than expected uterine size could be caused by her passing out some tissue earlier or it could be due to the foetus having been dead for some time. The finding of an open cervix would be in line with the fact that she had passed out some fetal tissue or it could signify that she is experiencing an inevitable miscarriage (while all fetal tissue is still kept within her uterus).

The likely diagnoses that should be considered for this case would be miscarriage (threatened, incomplete, complete and missed), cervical insufficiency, and ectopic pregnancy. A smaller than dates uterus and an open cervix makes threatened abortion an unlikely diagnosis. Her clinical findings could be expected in both an incomplete abortion and a complete abortion.
In ectopic pregnancy, although there would be a smaller than dates uterus, the cervical os would usually be closed. Cervical insufficiency is probable due to an open os but the uterine size would be expected to correspond to her dates, making it also less likely than a miscarriage.

Since she most likely has had a miscarriage (be it incomplete or complete), the next best step would be to do a per vaginal ultrasound scan which could show whether or not products of conception are still present within the uterine cavity. If present, it would be an incomplete miscarriage which would warrant a dilatation and curettage; if absent, it is a complete miscarriage so D&C would not be needed.

In view of her open cervix and 12 weeks of amenorrhea, there is no indication for a pregnancy test nor assessment of her beta-hCG levels. Cervical ligation would only be indicated if the underlying issue was cervical incompetence, which is not in this case.

The proximal attachment of the piriformis muscles is from the anterior surface of sacrum and it attaches distally to the superior border of the greater trochanter of the femur. It is innervated by the anterior rami of S1 and S2.

(13-20 weeks). If a mother has chickenpox in late pregnancy (5 days prior to delivery) then there is risk of neonatal varicella infection which may be severe.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. Though the primary host for the organism is the domestic cat, humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection which can lead to hydrocephalus, microcephaly, mental disability and vision loss.

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

The changes seen in breast tissue with the menstrual cycle are accentuated during pregnancy. Deposition of fat around glandular tissue occurs, and the number of glandular ducts is increased by oestrogen, while progesterone and human placental lactogen (hPL) increase the number of gland alveoli. Prolactin is essential for the stimulation of milk secretion and during pregnancy prepares the alveoli for milk production. Although prolactin concentration increases throughout pregnancy, it does not then result in lactation since it is antagonized at an alveolar receptor level by oestrogen.

Women, who have never had sexual encounter, do not need cervical screening. However, any sort of sexual encounter (Lesbian or heterosexual) is considered a risk and the patient must be screened. Otherwise, routine cervical screening test can be performed every five years for woman 25-74 years who ever had sex with no evidence of cervical pathology. Perform a cervical screening test at the age of 25 or 2 years after first sexual intercourse-whichever is later in sexually active women. Perform cervical screening test in patients above 75 years if they request or if they never had any symptoms.

All other options are unacceptable.

The contents of the femoral triangles are femoral nerve, artery and the vein. Along with the femoral sheath and lymphatics.

Maternal exposure to dietary factors during pregnancy can influence embryonic development and may modulate the phenotype of offspring through epigenetic programming. Folate is critical for nucleotide synthesis, and preconceptional intake of dietary folic acid (FA) is credited with reduced incidences of neural tube defects in infants.

Dizygotic means two (di) fertilized eggs (zygotes). Dizygotic twins occur when two eggs are fertilized by two separate sperm. Dizygotic twins are also known as fraternal or non-identical twins. They are the most common type of twins.

Unlike monozygotic twins (also known as identical twins), dizygotic twins do not share the same genes. Monozygotic twins share 100 percent of each other genes. Dizygotic twins share only 50 percent. This is the same genetic similarity found between siblings conceived and born at different times.

Pre-eclampsia presents with other features in addition to the presence of hypertension, also it’s diagnosis cannot be made considered peripheral edema as the only presenting symptom. Proteinuria occurs more commonly in pre-eclampsia than in gestational hypertension and the latter is mostly asymptomatic.

Hypertensive disorders are found to complicate about 10% of all pregnancies. Common one among them is Gestational hypertension, which is defined as the new onset of hypertension after 20 weeks of gestation without any maternal or fetal features of pre-eclampsia, in this case BP will return to normal within three months of postpartum.

Types of hypertensive disorders during pregnancy:
1. Pregnancy-induced hypertension:
a. Systolic blood pressure (SBP) above 140 mm of Hg and diastolic hypertension above 90 mmHg occurring for the first time after the 20th week of pregnancy, which regresses postpartum.
b. The rise in systolic blood pressure above 25 mm of Hg or diastolic blood pressure above 15 mm of Hg from readings before pregnancy or in the first trimester.
2. Mild pre-eclampsia:
BP up to 170/110 mm of Hg in the absence of associated features.
3. Severe pre-eclampsia:
BP above 170/110 mm of Hg and along with features such as kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise.
4. Essential (coincidental) hypertension:
Chronic underlying hypertension occurring before the onset of pregnancy or persisting after postpartum.
5. Pregnancy-aggravated hypertension:
Underlying hypertension which is worsened by pregnancy.

To diagnose pre-eclampsia clinically, presence of one or more of the following symptoms are required along with a history of onset of hypertension after 20 weeks of gestation.
– Proteinuria: Above 300 mg/24 h or urine protein
reatinine ratio more than 30 mg/mmol.
– Renal insufficiency: serum/plasma creatinine above 0.09 mmol/L or oliguria.
– Liver disease: raised serum transaminases and severe epigastric or right upper quadrant pain.
– Neurological problems: convulsions (eclampsia); hyperreflexia with clonus; severe headaches with hyperreflexia; persistent visual disturbances (scotomata).
– Haematological disturbances like thrombocytopenia; disseminated intravascular coagulation; hemolysis.

The incidence of monozygotic twins is constant worldwide (approximately 4 per 1000 births). Approximately two thirds of twins are dizygotic.

Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.

Traditional POP main mode of contraceptive action: thickening of cervical mucus Desogestrel-only POP main mode of contraceptive action is inhibition of ovulation Cerazette® is the only Desogestrel-only POP in the options above. Other desogestrel brands include: Aizea® Cerelle® Nacrez® The other POPs listed are considered traditional POPs and have the following compositions: Norgeston® – Levonorgestrel 30 mcg Micronor® & Noriday® – Norethisterone 350 mcg Femulen® – Ethynediol diacetate 500 mcg

Methotrexate is a folic acid antagonist. It inhibits dihydrofolate reductase (DHFR). DHFR catalyses the conversion of dihydrofolate to the active tetrahydrofolate which is required for DNA synthesis. It is either administered as a single intramuscular injection or multiple fixed doses.

The principal screening test for detecting maternal HBV infection is the serologic identification of HBsAg. Screening should be performed in each pregnancy, regardless of previous HBV vaccination or previous negative HBsAg test results.

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (e.g., injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Interventions to prevent perinatal transmission of HBV infection include screening all pregnant women for HBV, vaccinating infants born to HBV-negative mothers within 24 hours of birth, and completing the HBV vaccination series in infants by age 18 months.

The bladder is supplied by branches of the internal iliac artery, including the superior vesical artery, branches of the gluteal and obturator arteries and the inferior vesical artery in males and the vaginal and the uterine arteries in females.

A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour

If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.

Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.

No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.

Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin.

Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. 

There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.

The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.

Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.

Bacterial vaginosis (BV) is a clinical condition characterized by a shift in vaginal flora away from Lactobacillus species toward more diverse bacterial species, including facultative anaerobes. The altered microbiome causes a rise in vaginal pH and symptoms that range from none to very bothersome. Future health implications of BV include, but are not limited to, increased susceptibility to other sexually transmitted infections and preterm birth. Fifty to 75 percent of women with BV are asymptomatic. Symptomatic women typically present with vaginal discharge and/or vaginal odour. The discharge is off-white, thin, and homogeneous; the odour is an unpleasant fishy smell that may be more noticeable after sexual intercourse and during menses.

During follicular phase, there is an increase in gonadotrophin hormones and a proliferation of the endometrium occurs. The duration of the cycle depends upon the overall length of the menstrual cycle. The progesterone levels are increased in the luteal phase and not in follicular phase.

Oestrogen-containing contraceptives are not recommended for this woman since she has a history of DVT. This is most likely why she was started on POP instead of standard combination tablets prior. Progesterone is also contraindicated with a history of ectopic pregnancy and should never be used again. Barrier approaches, for example, could be applied in this woman’s case.
The following are absolute contraindications to taking just progesterone pills:
– Pregnancy
– Breast cancer
– Vaginal bleeding that hasn’t been diagnosed
– Ectopic pregnancy history or a high risk of ectopic pregnancy

Progesterone-only pills have the following relative contraindications:
– Active viral hepatitis
– Severe chronic liver disease
– Malabsorption syndrome
– Severe arterial disease
– Successfully treated breast cancer more than 5 years ago
– Concomitant use of hepatic enzyme inducing medications.

Fertilization usually occurs in the fallopian tubes after ovulation. The zygote moves through the fallopian tube and implants in the endometrium about 7-9 days after fertilisation, or 6-12 days after ovulation.

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extra pelvic endometriosis may rarely occur.

Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Though ESR maybe elevated due to the presence of inflammation, it is not specific for endometriosis and has no role in preoperative staging. The same holds true for any possible CBC finding.

Transvaginal ultrasound is preferred for diagnosis but doesn’t aid in preoperative staging of endometriosis.

CA125 values are elevated in severe infiltrative endometriosis but unchanged in mild disease. Relaying on CA125 cause a high rate of false negatives.

Firstline medical management of PCOS is with clomiphene.

Ovulation Disorders

WHO Group I : Hypothalamic pituitary failure (Stress, anorexia, exercise induced)
Management:
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation

WHO Group II : Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Management:
Weight reduction if BMI >30
Clomiphene/Clomiphene (1st line)
Metformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)

WHO Group III : Ovarian failure
Management:
Consider IVF with donor eggs

Retarded skeletal growth resulting in small for gestational age babies are the usual outcomes of an untreated vitamin D deficiency in pregnancy.

Symptoms associated with maternal vitamin D deficiency during pregnancy are:
– Hypocalcemia in newborn.
– Development of Rickets later in life.
– Defective tooth enamel.
– Small for gestational age due to its effect on skeletal growth
– Fetal convulsions or seizures due to hypocalcemia.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

In this case, the patient has a missed abortion, which is defined as a dead foetus or embryo without passage of tissue and with a closed cervix. This condition often presents with failure to detect fetal heart tones or a lack of growth in uterine size.

– By 14 weeks estimated gestational age, fetal heart tones should be detected by both handheld Doppler and ultrasonography.
– An inevitable abortion presents with a dilated cervix, but no passage of fetal tissue.
– A blighted ovum involves failure of the embryo to develop, despite the presence of a gestational sac and placental tissue.

Most of the cases of down syndrome occur due to non disjunction trisomy 21 which is associated with increased maternal age. The non disjunction occurs in the maternal gametes.

Ovarian insufficiency is a failure of the ovary to function adequately in a woman younger than 40 years, in its role either as an endocrine organ or as a reproductive organ. In women aged 40 years or older, the expected physiologic decline of ovarian function that takes place with aging is termed perimenopause or the menopausal transition.
Medical treatment of patients with primary ovarian insufficiency should address the following aspects:

Ovarian hormone replacement
Restoration of fertility
Psychological well-being of the patient

It is not appropriate to give this patient contraceptive pills since she desires pregnancy.

There is no evidence that Danazol or Metformin would improve ovarian follicle function.

It is usual to experience heavy, continuous bleeding around the time of menarche.
Haemoglobin and ferritin levels are used to determine the severity of bleeding and its impact on the haemoglobin level.
These analyses do not pinpoint the source of the problem, but they do pinpoint its consequences.
A haematologic reason, such as thrombocytopenia, acute leukaemia, or a coagulation/bleeding issue, affects about one-third of girls with pubertal menorrhagia (e.g. von Willebrand disease).
A complete blood examination and a bleeding
lotting profile are required to rule out these illnesses.
The results of a haemoglobin estimation or a ferritin level evaluation are insufficient, and the results of dilatation and curettage (D&C) or magnetic resonance imaging (MRI) will rarely reveal the reason for the bleeding.

Maternal blood volume expands during pregnancy to allow adequate perfusion of vital organs, including the placenta and foetus, and to anticipate blood loss associated with delivery. The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. While there is some increase in intracellular water, the most marked expansion occurs in extracellular fluid volume, especially circulating plasma volume. This expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Overall, total body water increases from 6.5 to 8.5 L by the end of pregnancy.

The venous drainage of the uterus is via the uterine veins which form a plexus passing below the artery within the base of the broad ligament communicating with the rectal and the vesical venous plexus before draining into the internal iliac veins.

During mid secretory phase, the endometrium cells undergo distension, become more tortuous and are lined by columnar cells.
In the early proliferative phase, the glandular epithelium is cubo-columnar, while in the late proliferative phase, the glands increase in size, becoming tortuous and there is pseudostratification of the epithelium.

Treatment with Clomiphene should not exceed 6 months.

The yolk sac increases in size up until the 10th week reaching a maximum diameter of 6mm in normal pregnancy. After the 10th week the yolk sac will gradually disappear. It is usually sonographically undetectable by 20 weeks. A yolk sac greater than 6mm diameter is suspicious of failed pregnancy.

The placenta does not have all the necessary enzymes to make oestrogens from cholesterol, or even progesterone. Human trophoblast lack 17-hydroxylase and therefore cannot convert C21-steroids to C19-steroids, the immediate precursors of oestrogen. To bypass this deficit, dehydroisoandrosterone sulphate (DHA) from the fetal adrenal is converted to estradiol-17ί by trophoblasts. In its key location as a way station between mother and foetus, placenta can use precursors from either mother or foetus to circumvent its own deficiencies in enzyme activities.

A fibroid is a benign smooth muscle tumour or Leiomyoma. As such it is something of a misnomer. Leiomyosarcoma and Angioleiomyoma are malignant tumours of smooth muscle under the WHO sort tissue tumour classification Rhabdomyoma is a skeletal muscle tumour Myofibroma is seen in fibromatosis

Proteinuria of more than 1+ on dipstick should be investigated to quantify the amount of proteinuria. A protein: creatinine ratio can be used to determine the severity of proteinuria, where levels of more than 30 mg/mmol indicate significant proteinuria.

The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labour soon. They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.

Chlamydia trachomatis (D-K subtypes) is the most common cause in this age group and fits the descriptors given.

Placenta previa typically presents with painless bright red vaginal bleeding usually in the second to third trimester. Although it’s a condition that sometimes resolves by itself, bleeding may result in serious complications for the mother and the baby and so it should be managed as soon as possible.

The arcuate line is a smooth rounded border on the internal surface of the ilium just inferior to the iliac fossa. It forms the boundary of the pelvic inlet.

The treatment of asphyxia starts with the correct perinatal management of high-risk pregnancies. The management of the hypoxic-ischemic new-borns in the delivery room is the second fundamental step of the treatment. Low Apgar scores and need for cardiopulmonary resuscitation at birth are common but nonspecific findings. Most new-borns respond rapidly to resuscitation and make a full recovery. The outcomes for new-borns who do not respond to resuscitation by 10 minutes of age are very poor, with a very low probability of surviving without severe disability. Resuscitation in room air is advised for term new-borns, since the use of 100% oxygen is associated with worse outcomes compared to the use of room air.

The patient is presenting with classic symptoms of round ligament pain.
Round ligaments are structures which extends from the lateral portion of the uterus below to the oviduct and will travel downward in a fold of peritoneum to the inguinal canal to get inserted in the upper portion of the labium majus. As the gravid uterus grows out of pelvis during pregnancy, these ligaments will stretch, mostly during sudden movements, resulting in a sharp pain. Due to dextrorotation of uterus, which occurs commonly in pregnancy, the round ligament pain is experienced more frequently over the right side. Usually this pain improves by avoiding sudden movements, by rising and sitting down gradually, by the application of local heat and by using analgesics.

As the patient is not experiencing any symptoms like fever or anorexia a diagnosis of appendicitis is not likely. Also in pregnant women appendicitis often presents as pain located much higher than the groin area as the growing gravid uterus pushes the appendix out of pelvis.

As the pain is localized to only one side of groin and is alleviated with a heating pad the diagnosis of preterm labor is unlikely. In addition, the pain would persist even at rest and not with just movement in case of labor.

As the patient has not reported of any urinary symptoms diagnosis of urinary tract infection is unlikely.

Kidney stones usually presents with pain in the back and not lower in the groin. In addition, with a kidney stone the pain would occur not only with movement, but would persist at rest as well. So a diagnosis of kidney stone is unlikely in this case.

Gas gangrene is synonymous with myonecrosis and is a highly lethal infection of deep soft tissue, caused by Clostridium species, with Clostridium perfringens being the most common. This organism has also had increased incidence as the cause of deep tissue infections associated with childbirth and infections after gynaecologic procedures including septic abortions, which can cause gas gangrene of the uterus.
Health care workers should suspect gas gangrene if anaerobic gram-positive bacilli are present in a wound with necrosis of soft tissue and muscle. The organisms produce a gas identifiable on x-ray or CT scans.
Patients with gas gangrene (myonecrosis) present with signs of infection such as fever, chills, pain, and less superficial inflammation at the site of infection than one would expect given the deep penetrating nature of these infections. The condition of the patient can rapidly progress to sepsis and death if not treated aggressively. The wound discharge is often dishwater looking with a musty order.

The GI tract forms from the endoderm. The endoderm grows laterally and then ventrally finally folding on its self to form the gut tube.

The incubation period of varicella is 10-21 days.

Endocrine hormones are released from their site of origin and travel through the blood to act on other distant target organs. Autocrine hormones act within the same cell and exocrine glands secrete their products into ducts.

Androgen insensitivity syndrome means that patients are phenotypically males but they are resistant or insensitive to male androgen hormones. They do not have a uterus. Due to insensitivity to androgens these patients often have female traits but their genetic makeup is of male, 46XY.

Adenomyosis is a disorder characterised by the presence of endometrial glands deep within the myometrium. It presents with increasing severe secondary dysmenorrhoea and increased in the flow of menstrual blood.

Women with Beta-Thalassaemia require significant extra input during pregnancy. Folic acid 5 mg daily should be commenced 3 months prior to conception in these patients. NOTE Women with thalassaemia who have undergone splenectomy OR have a platelet count >600 should continue or be commenced on Aspirin (75 mg/day)

The most probable cause of her presentation is a mixed infection with Chlamydia trachoma and vaginal pathogens.

Her most likely diagnosis is pelvic inflammatory disease (PID) as suggested by a purulent vaginal discharge alongside a fever which indicates a systemic infection.

The most common causative organisms in PID after sexual activity are chlamydia and gonorrhoea, of which chlamydia has a much higher prevalence.

Chlamydia has also been shown to be present in about 15% of subjects who underwent pregnancy termination with no constant sexual partner.

PID occurring after a gynaecologic surgical procedure is most commonly a result of mycoplasma or vaginal pathogens.

This patient presents because of significant mood changes since she gave birth to her child: she is sad most of times and she is having guilt feelings about her adequacy for motherhood- She is also complaining of insomnia, tiredness, and even some suicidal ideation. These symptoms are highly suggestive postpartum depression. This should be differentiated from postpartum blues, which usually present within the first 2 weeks and last for few days. This patient’s symptoms started 5 weeks postpartum. Postpartum depression usually presents within the first 6 weeks to the first year postpartum.

Postpartum depression is the most common complication of childbearing and affects the mother, the child, and relationship with the partner. It is diagnosed the same way as major depressive disorder in other patients. Since untreated postpartum depression can have long-term effects on the mother and the child, appropriate therapy should be undertaken as soon as possible- Antidepressant medications such as sertraline can be used to treat postpartum depression. In a patient who has suicidal ideation, electroconvulsive therapy has a more rapid and effective action than medication and should be considered in these patients.

→ Cognitive behavioural therapy is effective in women with mild to moderate postpartum depression; it would not be a good choice in this patient with suicidal ideation and at risk of harming the baby.
→ Estrogen therapy used alone or in combination with antidepressant, has been shown to significantly reduce the symptoms of postpartum depression; however, it would not be the most appropriate choice in a patient with suicidal ideation.
→ Peer support has shown equivocal results in various studies even though most postpartum patients report that lacking an intimate friend or confidant or facing social isolation are factors leading to depression.
→ Non-directive counselling also known as ”listening visits“ has been found to be effective in postpartum patients, though the studies that were conducted are deemed to be of small sample and larger studies still need to be done to validate these findings. It would not be an appropriate choice for this patient with suicidal ideation.

Spinnability (or Spinnbarkeit), which measures the capacity of fluids to be drawn into threads, represents an indirect measurement of the adhesive and elastic properties of mucus.

Gonorrhoea is a diplococcus bacteria known to infect the female genital tract. The bacteria is sexually transmitted and can cause an ascending infection in the uterus and fallopian tubes. According to the BASHH guidelines (British Association for Sexual Health and HIV), indication for therapy include confirmation of intracellular diplococci on microscopy or a confirmed positive NAAT. Treatment of gonorrhoea in pregnancy is as follows: Ceftriaxone 1g intramuscularly as a single dose with azithromycin 2g oral as a single dose. Pregnant individuals are not to be treated with quinolones or tetracyclines.

Ulipristal is a progesterone receptor modulator that is used up to 120 hours following unprotected intercourse. It inhibits ovulation. The dose is 30 mg.

The clinical diagnosis of polycystic ovaries (PCO) is confirmed by the ultrasound. Therefore, the best next step to treat this woman’s infertility is to start treatment with metformin (correct answer). Patients with polycystic ovaries, frequently develop insulin resistance and metformin has been shown to be beneficial in this situation. Metformin treatment corrects any metabolic abnormalities and decreases insulin resistance resulting in a return of normal ovulatory menstrual cycles and a rapid improvement in fertility.

Additional treatment with clomiphene citrate may be required in some patients but gonadotrophin therapy is no longer commonly used.

Clomiphene citrate could also have been recommended as a possible next treatment option since the available data indicate that both clomiphene and metformin are equally effective.

Laparoscopic ovarian drilling has been used previously to treat polycystic ovaries; however, it is only used nowadays when all other treatment methods have been ineffective.

Similarly, gonadotrophin therapy or in vitro fertilisation would not be the best next step to treat the infertility and they are used when other treatment options have not provided the required results.

Even though changes in the semen analysis have been noted since the first pregnancy was achieved, these are not likely to be the cause of the secondary infertility, particularly because the current semen analysis is not significantly abnormal. Therefore, it is unlikely that donor insemination would be needed.

Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.

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.

The best strategy is to commence cyclical hormone therapy using continuous daily oestrogen therapy, with medroxy progesterone acetate (MPA) given daily for 12 days each month.

This patient is most likely experiencing menopause, with symptoms caused by her oestrogen deficiency state.

Diazepam will help her to sleep and possibly alleviate her irritability, but would be unlikely to relieve the hot flushes.

Continuous therapy with oestrogen and MPA provides continuous progestogen therapy and has a high risk of causing unpredictable breakthrough vaginal bleeding, as it is only three months since the last menstrual period. This treatment is not recommended to be given within 1 – 2 years of the last period.

Oestrogen alone is not recommended for women who still have their uterus.

Progestogen alone would only be indicated in cases with contraindications to oestrogen administration.

Closure of the uterus should be performed in either single or double layers with continuous or interrupted sutures. The initial suture should be placed just lateral to the incision angle, and the closure continued to a point just lateral to the angle on the opposite side. A running stitch is often employed and this may be locked to improve haemostasis. If a second layer is used, an inverting suture or horizontal suture should overlap the myometrium. Once repaired, the incision is assessed for haemostasis and ‘figure-of-eight’
sutures can be employed to control bleeding. Peritoneal closure is unnecessary. Abdominal closure is performed in the anatomical planes with high strength, low reactivity materials, such as polyglycolic acid or polyglactin. Diamorphine is advised for intra and post op analgesia and oxytocin is advised to reduce blood loss.

Mirena coil is used for contraception and for long term birth control. It causes stoppage of menstrual bleeding however, in a few cases there may be inter-menstrual spotting.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy, associated with weight loss of more than 5% of pre-pregnancy weight, dehydration and electrolyte imbalance. HG is usually most severe during the first 12 weeks of pregnancy and is thought to be caused by high circulating levels of HCG.

There is not yet any evidence that pregnancy itself increases the sensitivity of the area postrema, or that the hormones, oestradiol, or progesterone increase vomiting. Generally, higher concentrations of dopamine stimulates receptors in the chemoreceptor trigger zone leading to nausea and vomiting. Although this has not been demonstrated as the cause of hyperemesis gravidarum.

The following cardiovascular changes occur during pregnancy:
– Blood volume slowly increases by 40-50%
– Heart rate rises by 15 beats/min above baseline
– Stroke volume increases by 25-30%
– Cardiac output increases by approximately 30-50%
– Systemic vascular resistance (SVR) decreases by 20-30%
– Diastolic blood pressure consequently decreases between 12 and 26 weeks but increases again to pre-pregnancy levels by 36 weeks.
As most of the changes occur in the first 12 weeks of gestation cardiac problems are likely to present in early pregnancy

The risk factors for uterine carcinoma include obesity, diabetes, Nulliparity, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of ovarian or uterine carcinoma.

Patient mentioned in the case has developed thyrotoxicosis during pregnancy. TSH level should be tested, and if the result shows any suppressed or elevated TSH level, then it is mandatory to check for free T4 level.

In case a person tests positive for chlamydia, all sexual partners over the period of 6 months should to contacted and started on appropriate antibiotics.

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

Caesarean section is rarely needed to be done when the foetus is already dead.

Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

PMS is a condition, which is associated with somatic, emotional and behavioural symptoms during the women menstruation. Oenothera biennis with the common name of “evening primrose” is containing a valuable fixed oil with commercial name of EPO. Evening primrose oil has two types of omega-6-fatty acid including linoleic acid (60%–80%) and γ-linoleic acid (8%–14%). Essential fatty acids are considered as essential compounds for body health, especially among women. Evening primrose oil’s is effective in women health, but the immediate response should not be expected from it, therefore, it should be regularly used up to 4 or 6 months.

Oral contraceptive pills are only used when other treatments fail.
SSRI are only indicated in cases of persistent mood changes like depression.
Local anaesthetics have no role in the management of PMS.

Skin signs during pregnancy may include: dark spots on the breasts, nipples and inner thighs, melasma (chloasma), linea nigra, stretch marks, acne, spider telangiectasis and varicose veins.

Early decelerations: a result of increased vagal tone due to compression of the fetal head during contractions. Monitoring usually shows a symmetrical, gradual decrease and return to baseline of FHR, which is associated with a uterine contraction.

The best treatment option for chlamydial urethritis in pregnancy is Azithromycin 1g as a single dose orally. This is the preferred option as the drug is coming under category B1 in pregnancy.

Tetracycline antibiotics, including doxycycline, should never be used in pregnant or breastfeeding women.

Erythromycin Estolate is contraindicated in pregnancy due to its increased risk for hepatotoxicity. Ciprofloxacin is not commonly used for treating chlamydial urethritis and its use is not safe during pregnancy.

Detrusor overactivity can be treated with anti-cholinergic agents such as oxybutynin or tolterodine, solifenacin, fesoterodine and darifenacin. They are used as first line agents. Imipramine is used for enuresis and desmopressin is used for nocturia.
NICE pathway

Prior to initiating anticholinergics:
Bladder training
Consider treating vaginal atrophy and nocturia with topical oestrogen and desmopressin respectively before commencing treatments below.
Consider catheterisation if chronic retention
1st line treatments:
1. Oxybutynin (immediate release) – Do not offer to frail elderly patients
2. Tolterodine (immediate release)
3. Darifenacin (once daily preparation)
DO NOT offer any of the 3 drugs below:
1. Flavoxate
2. Propantheline
3. Imipramine
2nd line treatment
Consider transdermal anticholinergic (antimuscarinic)
Mirabegron
Adjuvant Treatments
Desmopressin can be considered for those with nocturia
Duloxetine may be considered for those who don’t want/unsuitable for surgical treatment
Intravaginal oestrogen can be offered to postmenopausal women with OAB

Mammary duct ectasia occurs when the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

The ovarian arteries, arising from the abdominal aorta and the ascending uterine arteries which are branches of the internal iliac artery all supply the ovaries. They terminate by bifurcating into the ovarian and tubal branches and anastomose with the contralateral branches providing a collateral circulation.

When the red cells are coated with immune IgG antibody, the cells do not agglutinate but when anti-IgG antiserum is added to these sensitized cells visible agglutination occurs. This is known as a positive direct coombs test.

The first sign of puberty in females is the development of breasts.

The average volume of uterine blood flow at term is 500-750 ml/min.

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

Venous thromboembolic disease (VTE) is the most common cause of direct maternal death in the UK. In the most recent triennium, there were 41 fatalities, giving a maternal mortality rate of 1.94 per 100 000 – more than twice that of the next most common cause, pre-eclampsia. As pregnancy is a hyper coagulable state. There are alterations in the fibrinolytics and thrombotic pathways. There is also an increased production of clotting factors during pregnancy.

PMNs phagocytise debris and kill bacteria via free radicals (AKA respiratory burst). They also break down damaged tissue. PMNs typically undergo apoptosis after 48 hours. They are then engulfed and degraded by macrophages. Macrophages therefore become the predominant cell type in the wound on days 3-4.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. The primary host for the organism is the domestic cat. Humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection can lead to hydrocephalus, microcephaly, mental disability and vision loss.

Clomiphene and/or Metformin are 1st line agents. Weight loss in the setting of subfertility is advised if BMI >30 kg/m2

The contents of the broad ligament:
Fallopian tubes
Ovarian artery
Uterine artery
Ovarian ligament
Round ligament of uterus

It is stage 2B. Stage I: is strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion.
2010 FIGO classification of cervical carcinoma:
Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.

Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
Stage IB1: Clinical lesions no greater than 4 cm in size.
Stage IB2: Clinical lesions greater than 4 cm in size.

Stage II: carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall.

Stage III: carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.

Stage IV: carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.
Stage IVA: Spread of the tumour into adjacent pelvic organs.
Stage IVB: Spread to distant organs.

Ventilation begins to increase significantly at around 8 weeks of gestation, most likely in response to progesterone-related sensitization of the respiratory centre to carbon dioxide and the increased metabolic rate. Significant alterations occur in the mechanical aspects of ventilation during pregnancy. Minute ventilation (or the amount of air moved in and out of the lungs in 1 minute) is the product of tidal volume and respiratory rate and increases by approximately 30–50 per cent with pregnancy. The increase is primarily a result of tidal volume, which increases by 40 per cent (from 500 to 700 mL), because the respiratory rate remains unchanged. The increase in minute ventilation is perceived by the pregnant woman as shortness of breath, which affects 60–70 per cent of women. This physiological dyspnoea is usually mild and affects 50 per cent of women before 20 weeks gestation, but resolves immediately postpartum.

The NICE guidelines on Hypertension in pregnancy define blood pressure in pregnancy as follows:
Mild hypertension: DBP=90-99 mmHg, SBP=140-149 mmHg. Moderate hypertension: DBP=100-109 mmHg, SBP=150-159 mmHg.
Severe hypertension: DBP=110 mmHg or greater, SBP=160 mmHg or greater.

Anencephaly means the missing of a particular portion of the scalp and brain tissue. The other factors listed are associated with umbilical cord prolapse like multiparity, twin birth, polyhydramnios, premature delivery, long umbilical cord or breech presentation.

Multiparous women active 2nd stage labour: Suspect delay if progress inadequate after 30 minutes Diagnose delay if progress inadequate after 1 hour If delay is suspected amniotomy should be offered if membranes are intact If delay diagnosed then preparations should be made for C-section Nulliparous women active 2nd stage labour: Suspect delay if progress inadequate after 1 hour Diagnose delay if progress inadequate after 2 hours If delay is suspected amniotomy should be offered if membranes are intact If delay diagnosed then preparations should be made for C-section

of cases there is no permanent neurological disability. Shoulder dystocia is the most common cause of Erb’s palsy (Erb-Duchenne palsy) where there is injury to C5 and C6 of the brachial plexus (C5 to T1)

For pregnant women who are screened and rubella antibody is not detected, rubella vaccination after pregnancy should be advised. Vaccination during pregnancy is contraindicated because of a theoretical risk that the vaccine itself could be teratogenic, as it is a live vaccine. No cases of congenital rubella syndrome resulting from vaccination during pregnancy have been reported. However, women who are vaccinated postpartum should be advised to use contraception for three months.

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.

Among all the antiepileptic drugs sodium valproate carries the highest teratogenicity rate. The potential congenital defects caused by sodium valproate are as below:
– Neural tube defects like spina bifida, anencephaly
– Cardiac complications like congenital ventricular septal defect, aortic stenosis, patent ductus arteriosus, aberrant pulmonary artery
– Limb defects like polydactyly were more than 5 fingers are present, oligodactyly were less than 5 fingers are present, absent fingers, overlapping toes, camptodactyly which is presented as a fixed flexion deformity of one or more proximal interphalangeal joints,split hand, ulnar or tibial hypoplasia.
– Genitourinary defects like hypospadias, renal hypoplasia, hydronephrosis, duplication of calyceal system.
– Brain anomalies like hydranencephaly, porencephaly, arachnoid cysts, cerebral atrophy, partial agenesis of corpus callosum, agenesis of septum pellucidum, lissencephaly of  medial sides of occipital lobes, Dandy-Walker anomaly
– Eye anomalies like bilateral congenital cataract, optic nerve hypoplasia, tear duct anomalies, microphthalmia, bilateral iris defects, corneal opacities.
– Respiratory tract defects like tracheomalacia, lung hypoplasia,severe laryngeal hypoplasia, abnormal lobulation of the right lung, right oligemic lung which is presented with less blood flow.
– Abdominal wall defects like omphalocele
– Skin abnormalities capillary hemangioma, aplasia cutis congenital of the scalp.

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.

Providers should identify any known risk factors for ectopic pregnancy in their patient’s history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment.

Performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy.

Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration.

Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. The patient may have a cervical ectopic pregnancy and would thus run the risk of haemorrhage and potential hemodynamic instability if a dilation and curettage are performed.

The risk of transplacental transmission from mother to foetus is greater in later pregnancy i.e. 26-40 weeks. Although the risk of transmission is lower in early pregnancy, if infection does occur earlier, particularly before 10 weeks, then complications are typically more severe.

Shoulder dystocia occurs when the bisacromial diameter, which is the breadth of the shoulders, exceed the diameter of pelvic inlet. This typically results in a bony impaction of the anterior shoulder against the maternal symphysis pubis, instead of an arrest at the pelvic inlet. Brachial plexus palsies including Erb’s palsy is the most common foetal injury associated with shoulder dystocia.

It is not hyper-extension but the hyper-flexion of maternal legs tightly on her abdomen, called as McRoberts manoeuvre, which facilitates delivery during shoulder dystocia. This technique is effective as it increases the mobility of sacroiliac joint during pregnancy, which allows the rotation of pelvis and thereby facilitating the release of fetal shoulder.
If this manoeuvre does not succeed, another technique called suprapubic pressure is done where an assistant applies pressure on the lower abdomen and gently pulls the delivered head. This technique is useful in about 42% of cases with shoulder dystocia.

Maternal diabetes mellitus and foetal macrosomia both are a risk factor for shoulder dystocia.

Administration of epidural anaesthesia during labour increases the possibility of shoulder dystocia.

Risk of shoulder dystocia may increase with Oxytocin augmentation also.

This is not an X-linked condition so the sex of the child makes no difference to the inheritance. Any child will have a 1 in 4 chance of having beta thalassaemia major.

Women with diabetes have increased risk for adverse maternal and neonatal outcomes and similar risks are present for either type 1 or type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies, and to minimize risk of congenital defects. Haemoglobin A1c goal at conception is <6.5% and during pregnancy is <6.0%.

The use of anticoagulants during pregnancy is a complicated issue because warfarin is teratogenic if used in the first trimester, and is linked with fetal intracranial haemorrhage in the third trimester (mainly at doses 5 mg daily). Low molecular weight heparin may be insufficient at preventing thrombosis in women with mechanical prosthetic heart valves, where the risk of valve thrombus is 10 per cent. Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension, or artificial valve replacements, and in those in or at risk of atrial fibrillation. The options are either to continue warfarin for the pregnancy, or replace it with heparin between 6 and 12 weeks gestation to avoid the teratogenic risk. Warfarin should be started a week after delivery.

This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.

There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.

The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve (S2-4) while the internal anal sphincter is innervated by autonomic nerves.

This patient had postmenopausal vaginal haemorrhage and an 8mm endometrial thickness. Endometrial thickness of 4mm or more in a postmenopausal woman with vaginal bleeding necessitates an endometrial biopsy to rule out endometrial cancer, and this patient should be referred to a gynaecologist for this procedure.
All of the other choices are incorrect.

During the last decade hysteroscopy has become the tool of choice for the evaluation of the endometrial cavity, including for assessment of abnormal uterine bleeding (AUB). Many clinicians would consider that, in most patients, the combination of transvaginal sonography and out-patient endometrial biopsy with diagnostic hysteroscopy could replace the need for dilation and curettage. Hysteroscopy was reported to have sensitivity, specificity, negative predictive value and positive predictive value of 94.2, 88.8, 96.3 and 83.1% respectively, in predicting normal or abnormal endometrial histopathology.

The highest accuracy of hysteroscopy was in diagnosing endometrial polyps, whereas the worst result was in estimating hyperplasia. Therefore, since the incidence of focal lesions in patients with AUB is high, it seems that the most beneficial approach is to proceed with hysteroscopy complemented by endometrial biopsy early in the assessment of AUB.

Transabdominal and transvaginal ultrasounds can be used but are inferior to hysteroscopy.

Coagulation profile can only diagnose possible coagulopathies and pregnancy test can only diagnose pregnancy. All other causes can not be identified with these laboratory investigations.

In normal pregnancy the levels of hCG doubles after every 48-72 hours but in case of ectopic pregnancy the levels of hCG are lower than the normal. It is produced by the placenta and its main role is nourishment of the egg after implantation. Its levels reached a peak at 8-10 weeks of pregnancy and after that the levels decreases for the remainder of pregnancy. In hydatiform mole and trophoblastic diseases its the main hormone for diagnosis of the disease because the levels are highly elevated.

It is less common for a girl of this age to develop fibroids, endometriosis and endometrial polyps, although these are all causes of severe dysmenorrhea. Chronic pelvic infection can be due to sexually transmitted disease but the history does not mention any previous episodes of pelvic pain or symptoms of infection such as fever. In this case, it is most likely that she has primary dysmenorrhea. Primary dysmenorrhea, in which no pathological cause can be identified, is believed to be due to the prostaglandins released by the secretory endometrium. If secondary dysmenorrhea is suspected, then endometriosis would be the most prominent cause.

While hysteroscopic and laparoscopic examinations are commonly done in adult women to rule out organic causes such as those mentioned earlier, in younger girls, they are usually only carried out if pain management with, for example, NSAIDs and the use of COCPs, have failed to either provide symptom relief or reduction.

Engagement means when the fetal head enters the pelvic brim/inlet and it usually takes place 2 weeks before the estimated delivery date i.e. at 38 weeks of pregnancy.

All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

The external carotid develops from the 1st arch. The common and internal carotid develop from the 3rd arch.

Hysterosalpingography is used to assess the patency of the fallopian tubes. It is performed by injection of a radio-opaque iodine based contrast. This test is contraindicated in pelvic inflammatory disease and during pregnancy. Should be performed in Follicular phase of menstrual cycle after cessation of menstrual bleeding and prior to ovulation (days 6-12).

Anti phospholipid syndrome is an autoimmune disorder in which abnormal antibodies are formed which increases the risk of blood clots to develop in vessels and leads to recurrent miscarriages to occurs. The changes of recurrent miscarriage in a previously known case of APL is 15%.

The correct answer is reassurance after thorough examination. Most breast lesions diagnosed during pregnancy and lactation, even some specific ones such as lactation and adenoma galactocele, are benign. The diagnosis of breast cancer, which is difficult to elucidate and is less common among women who are pregnant or lactating than among those of the same age who are not, continues to be a challenge for clinicians.

The progestogen-only pill (POP) is a contraceptive option for women who have high blood pressure either induced by use of combined oral pills or due to other causes; as long as it is well controlled and monitored. Combined oral contraception (COC) and Depo-Provera have been implicated in increased cardiovascular risk following use. High blood pressure has been theorized to be the critical path that leads to this increased risk. POP is the recommended method for women who are at risk of coronary heart disease due to presence of risk factors like hypertension.

Stopping OCP will risk in the patient getting pregnant. Cessation of oestrogen usually reverses the blood pressure back to normal, Hence, all other options are incorrect.

Hyaline degeneration is the most common form of fibroid degeneration. Fibroids:
Risk Factors
– Black Ethnicity
– Obesity
– Early Puberty
– Increasing age (from puberty until menopause)
Protective Factors
– Pregnancy
– Multiparity

Only little volumes of urine are lost when her intra-abdominal pressure is elevated during coughing, laughing, jumping, and straining, which is the only symptom associated with real stress incontinence.
The other reactions are significantly more compatible with a detrusor instability diagnosis (also called urge incontinence).
If she had incontinence throughout pregnancy, it would have been stress in nature, which is what her current incontinence is.

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.

Taking into consideration that she had only missed one pill and that they were going to be stopped the next day anyway, the rate of pregnancy would be low; hence all of the responses would be acceptable and effective. However, the most appropriate step would be to initiate her hormone-free interval starting from the time she missed her pill i.e. 11pm the night before. This would make tonight the 2nd lactose pill day and hence she should commence the next course of hormone pills on the 5 nights from tonight. In doing this, her hormone-free period would be the usual length of 7 days. Although the risk of pregnancy is low after missing only one pill, this opposite occurs when the missed pill causes a longer than normal hormone-free duration between the end of the current cycle and the starting of the subsequent one.

Fibrinogen is activated by thrombin which converts it into fibrin which forms a mesh to trap red blood cells and form a clot.

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface, resulting in a local inflammatory response and, in later pregnancy, thrombosis of the uteroplacental vasculature. This patient should be offered referral to a specialist clinic as she has had recurrent miscarriages. Low dose aspirin is one of the treatment options to prevent further miscarriage for patients with antiphospholipid syndrome.

Vaginismus is an uncontrollable painful spasm of the pelvic muscles and vaginal exit that this patient has. It’s mainly caused by psychological factors. It’s important to distinguish it from frigidity, which indicates a lack of sexual desire, and dyspareunia, which is characterized as pelvic and/or back pain or other discomfort linked with sexual activity. Endometriosis, pelvic adhesions, and ovarian neoplasms are all common causes of dyspareunia. Vaginismus pain can be psychogenic, or it might be caused by pelvic diseases like adhesions, endometriosis, or leiomyomas. Organic vulvar or pelvic reasons (such as atrophy, Bartholin gland cyst, or abscess) are extremely rare, hence vaginismus is mostly treated with psychotherapy.

This patient presents with secondary amenorrhea, most likely caused by Asherman’s syndrome- Secondary amenorrhea is defined as absence of menstruation for – 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea- Asherman’s syndrome as the cause of her amenorrhea is suggested by its beginning shortly after undergoing elective abortion. It is an outflow tract obstruction caused by intrauterine synechiae resulting from the procedure.

The best diagnostic test to confirm this diagnosis is hysteroscopy. It can allow visualization of the uterine cavity, the nature and extent of intrauterine synechiae.

→ Progesterone withdrawal test is one of the diagnostic studies done in the early work-up of secondary amenorrhoea- It is usually followed by the estrogen-progesterone challenge test and other tests. Progesterone withdrawal test alone would not confirm Asherman’s syndrome.
→ Pelvic ultrasound is more useful in primary amenorrhea work-up when the presence or absence of the uterus is to be confirmed- It is not very useful in the evaluation of intrauterine adhesions.
→ Brain MRI is useful in confirming the presence of pituitary tumours in patients, who are found to have high levels of prolactin. This patient’s most likely cause of secondary amenorrhea is Asherman’s syndrome.
→ TSH and prolactin levels should be the next step in the work-up of secondary amenorrhea after pregnancy has been ruled out; however, these studies cannot confirm Asherman’s syndrome.

Warfarin inhibits Vitamin K dependent clotting factors. These include factors 2,7,9 and 10.

The placenta produces Estriol from 16-OH DHEAS. Estriol is the major oestrogen (oestrogen) of pregnancy and the placenta is the primary site of production. Pregnenolone is synthesised by the placenta from cholesterol and this is converted to dehydroepiandrosterone (DHEA) in the fetal adrenal gland

The normal fetal heart rate ranges from 120-160 beats per minute in the uterine period.

The vaginal epithelium is made of squamous cells. Hence the most common carcinoma that occurs in the Vagina is squamous cell carcinoma. Diagnosis is made with vaginal biopsy. Usually the pain only presents if the disease extends beyond the vagina involving the perineal nerves.

On reflex liquid-based cytology, this patient had a cervical screening test that revealed HPV non-16 and 18 kinds, as well as a low-grade squamous intraepithelial lesion. In a year, she should be provided a cervical screening test. If HPV non-16/18 kinds are discovered in 12 months, she will need a colposcopy.

The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.

During fertilization, a sperm must first fuse with the plasma membrane and then penetrate the female egg cell to fertilize it. Fusing to the egg cell usually causes little problem, whereas penetrating through the egg’s hard shell or extracellular matrix can be more difficult. Therefore, sperm cells go through a process known as the acrosome reaction, which is the reaction that occurs in the acrosome of the sperm as it approaches the egg. The acrosome is a cap-like structure over the anterior half of the sperm’s head. Upon penetration, if all is normally occurring, the process of egg-activation occurs, and the oocyte is said to have become activated. This is thought to be induced by a specific protein phospholipase c zeta. It undergoes its secondary meiotic division, and the two haploid nuclei (paternal and maternal) fuse to form a zygote. To prevent polyspermy and minimize the possibility of producing a triploid zygote, several changes to the egg’s cell membranes render them impenetrable shortly after the first sperm enters the egg.

In the management of a miscarriage, after the completion of 7-14 days of expectant management, the woman is advised to take a pregnancy test after 3 weeks. In case of a positive result she is to return for further care.

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.

The nuchal lucency measurement is the measure of the nuchal pad thickness. Children with down syndrome have an increased thickness of the nuchal pad. The risk of down’s syndrome increases with maternal age. The nuchal lucency test has an accuracy rate of 70%.

A type II deceleration is due to placental insufficiency which can result in fetal distress and asphyxia. The fetal heart rate is lowest at the start of the contraction and returns to normal after the contraction is complete.

The posterior scrotal artery is a terminal branch of the perineal artery which is a branch of the internal pudendal artery.

Ultrasound findings in early pregnancy can help determine the viability of an intrauterine pregnancy. In the absence of a fetal heartbeat and no visible fetal pole, the mean gestational sac diameter should be measured. A sac diameter of less than 25mm on a transvaginal ultrasound scan is likely an indication of a miscarriage. In the presence of a fetal heartbeat, the crown-rump length should be less than 7mm according to NICE guidelines. Further scans are indicated 14 days later to confirm the diagnosis. The diagnosis of ‘pregnancy of uncertain viability’ is given in situations where there is inadequate ultrasound evidence to diagnose a miscarriage, such as a developing sac but no visualisation of a foetus with a heartbeat.
Ultrasound findings for partial molar pregnancy are an enlarged placenta with multiple diffuse anechogenic patches, while findings in a complete molar pregnancy include an enlarged uterus with multiple small anechogenic spaces (snowstorm appearance), or the bunch of grapes sign representing hydropic trophoblastic villi.

This patient has been unable to conceive for over a year, and her fallopian tubes are blocked. Her body mass index is 42.
Because she has obstructed Fallopian tubes, in-vitro fertilisation (IVF) is an alternative to getting pregnant for this patient.
A woman with a BMI over 35, on the other hand, will need twice as many IVF rounds to conceive as a woman of normal weight.
As a result, the greatest advise for successful IVF would be to decrease weight as the first step in management.
Obese (BMI less than 40) patients’ IVF success chances are reduced by 25% and 50%, respectively.

With the help of molding, the fetal head changes its shape as the skull bones overlap. This helps in smooth delivery of the foetus through the birth canal.

The treatment of stage 1A cervical cancer is excision of the margins using the Loop electrical excision procedure (LLETZ). Hysterectomy is not necessary. This treatment enables fertility to be preserved.

2010 FIGO classification of cervical carcinoma
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis 4A Invades mucosa bladder and rectum
4B – Distant Metastasis

Turner syndrome patients present with primary amenorrhea. These ladies have non functional or streak ovaries and they cant conceive. Their genetic traits is 45X. They have a shielded chest, webbed neck and low height. These patients suffer from primary amenorrhea.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 week old and is replaced by adult haemoglobin by the age of 5 months post natally. Only 2% of the haemoglobin is HbF.

Embryonic Haemoglobin:
Haemoglobin Gower 1 (HbE Gower-1)
Haemoglobin Gower 2 (HbE Gower-2)
Haemoglobin Portland I (HbE Portland-1)
Haemoglobin Portland II (HbE Portland-2)

Fetal Haemoglobin (haemoglobin F, HbF)

The right ovarian vein ascends and enters the inferior vena cava and the left ovarian vein drains into the longer left renal vein.

The proximal portion of urethra in females or membranous urethra in males is in the deep perineal pouch

Clavulanic acid is a beta-lactamase inhibitor that is most often combined with a penicillin to form Augmentin or Co-amoxiclav for greater antibiotic efficacy. The drug works by irreversibly binding to enzymes present in bacteria which posses the Beta-lactamase enzyme. This enzyme is responsible for inactivating Beta-Lactam antibiotics such as penicillin.

Increasing sample size decreases type 2 errors and increases power of the results. Sensitivity and specificity of the test should remain constant regardless of sample size. Confidence intervals are applied by a statistician and are dependent on the mean.

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. The intermittent vaginal bleeding and the requirement for manual removal of the placenta suggest endometritis as the most possible diagnosis.

Expected date of delivery (EDD) is a calculated from the first day of the woman’s last menstrual period. If her periods are regular i.e., 28-day menstrual cycle, Naegele’s rule may be used. Naegele’s rule involves a simple calculation: add seven days to the first day of your LMP and then subtract three months. e.g. 30 June + 7 days = 7 July, minus 3 months = 7 April.

The placenta accepts the blue, unoxygenated blood from the foetus through blood vessels that leave the foetus through the umbilical cord (umbilical arteries, there are two of them). When blood goes through the placenta it picks up oxygen and becomes red. The red blood then returns to the foetus via the third vessel in the umbilical cord, the umbilical vein. The red blood that enters the foetus passes through the fetal liver and enters the right side of the heart.

The pelvic outlet is bounded in front by the lower margin of the symphysis pubis, on each side by the descending ramus of the pubic bone, the ischial tuberosity and the sacrotuberous ligament, and posteriorly by the last piece of the sacrum. The AP diameter of the pelvic outlet is 13.5 cm and the transverse diameter is 11 cm.