Mitral stenosis is the most common cardiac condition affecting women during pregnancy and is poorly tolerated due to the increased intravascular volume, cardiac output and resting heart rate that predictably occur during pregnancy.

Young women may have asymptomatic mitral valve disease which becomes unmasked during the haemodynamic stress of pregnancy. Rheumatic mitral stenosis is the most common cardiac disease found in women during pregnancy. The typical increased volume and heart rate of pregnancy are not well tolerated in patients with more than mild stenosis. Maternal complications of atrial fibrillation and congestive heart failure can occur, and are increased in patients with poor functional class and severe pulmonary artery hypertension.

The Rotterdam criteria for the diagnosis of PCOS is based on a score of two out of the three criteria:
1) Oligo or anovulation
2) Hyperandrogenism – clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
3) on ultrasound – contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 cm3 or greater.

Antepartum haemorrhage is any bleeding that occurs from the female genital tract during the antenatal period after the 24+0 week of pregnancy and prior to the birth of the baby. The most common causes are placenta previa and placental abruption.

Afterpains may continue for 2-3 days (so none of the above). Breastfeeding may intensify pain due to stimulation of Oxytocin which causes uterine contractions

The anterior aspect of the vulva (mons pubis, anterior labia) is supplied by derivatives of the lumbar plexus: the anterior labial nerves, derived from the
ilio-inguinal nerve, and the genital branch of the genitofemoral nerve.
The posterior aspect of the vulva is supplied by derivatives of the sacral plexus: the perineal branch of the posterior cutaneous nerve of the thigh laterally, and the pudendal nerve centrally.

Above mentioned patient presented with symptoms of premature rupture of membranes (PROM) which refers to membrane rupture before the onset of uterine contractions.

A sudden gush of clear or pale yellow fluid from the vagina is the classic clinical presentation of premature rupture of membranes. Along with this the patient also developed signs of infection like fever, tachycardia and sweating which is suggestive of chorioamnionitis.

Vaginal examination is never performed in patients with premature rupture of membrane, instead a speculum examination is the usually preferred method which will show fluid in the posterior fornix.

The following are the steps in management of premature rupture of membrane:
– Admitting the patient to hospital.
– Take a vaginal
ervical smears.
– Measure and monitor both white cell count and C- reactive protein levels.
– Continue pregnancy if there is no evidence of infection or fetal distress.
– In presence of any signs of infection or if CTG showing fetal distress it is advisable to induce labour.
– Corticosteroids must be administered if delivery is prior to 34 weeks of gestation.
– Give antibiotics as prevention and for treatment of infection.

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

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.

Fetal urine contributes significantly to amniotic fluid production in the second trimester of pregnancy. As early as 8-11 weeks, urine production begins and can be observed in the fetal bladder on ultrasound scans. The urine creates a hypotonic fluid which contains increasing concentrations of urea and creatinine. By term, a foetus produces about 800 ml of urine a day, of which 250ml is eliminated through fetal swallowing.

Puerperal sepsis is defined as sepsis occurring after birth until 6 weeks postnatal. The most common cause of puerperal sepsis is Group A streptococcus. Until 1937, puerperal sepsis was the major cause of maternal mortality. The discovery of sulphonamides in 1935 and the simultaneous reduction in the virulence of the haemolytic streptococcus resulted in a dramatic fall in maternal mortality.

A complication of bilateral salpingo-oophorectomy and hysterectomy is the formation of adhesions in the GIT that can cause intestinal obstruction. Abdominal X-ray is sufficient to visualize any obstruction in the GIT.

Common Risk factors for Ovarian torsion are presence of an ovarian mass, women who are in their reproductive age and history of infertility treatment with ovulation induction.
Common clinical presentations include sudden onset of unilateral pelvic pain along with nausea & vomiting and presence of a palpable adnexal mass. An adnexal mass with absent Doppler flow to ovary can be noted in ultrasound.
Laparoscopy with detorsion, ovarian cystectomy and oophorectomy if necrosis or malignancy is found are the common treatment options.

Acute lower abdominal pain in a nonpregnant women can have various causes including pathologies of the gastrointestinal, gynecologic, or urologic systems due to the close proximity of these structures. All of these cases have classic presentations which help to characterize the disease process and thereby to differentiate the diagnosis.

In the given case, patient presents with right lower quadrant pain which is classic for ovarian torsion, occurring due to rotation of the ovary around the infundibulopelvic ligament, causing ovarian vessel occlusion.  Although ovarian torsion can occur in any women in their reproductive-age, is seen more commonly in those with a history of ovarian cysts (eg, hemorrhagic cyst) or masses (eg, mature cystic teratoma) because of the greater size and density of the ovary which makes it prone to rotation and subsequent torsion. Patients will initially have intermittent pain associated with activity, as in this patient, due to partial ovarian torsion, this initial pain resolves when the adnexa spontaneously untwists and blood flow returns. When this progresses to complete ovarian torsion, patients typically develop sudden-onset, severe, nonradiating pain due to persistent ischemia, which is often associated with nausea and vomiting.

Ovarian torsion can be clinically diagnosed, but a Doppler ultrasound is performed to evaluate ovarian blood flow and also to confirm the diagnosis. Surgical detorsion to prevent ovarian necrosis and cystectomy/oophorectomy are the usual treatment options.

Any association of urinary symptoms will help to establish a urologic cause of acute right lower quadrant pain like pyelonephritis, nephrolithiasis, etc.  However, patients with urologic conditions typically presents with suprapubic or flank pain which radiates to the right lower quadrant, making this diagnosis less likely in the given case.

A family history of malignancy usually does not aid in the diagnosis of acute lower abdominal pain. Although some ovarian cancers are inherited, patients with ovarian cancer typically have a chronic, indolent course with associated weight loss, early satiety, and abdominal distension.

Having multiple sexual partners is considered a risk factor for sexually transmitted infections and pelvic inflammatory disease, which can be a cause for lower abdominal pain. However, patients will typically have fever, constant and diffused pelvic pain along with rebound and guarding.

Recent sick contacts are a risk factor for gastroenteritis, which can present with nausea, vomiting and abdominal pain. However, in this case patient will typically have diffuse, cramping abdominal pain which will worsen gradually; along with persistent vomiting and diarrhea.

Ovarian torsion typically causes intermittent lower abdominal pain followed by sudden-onset of severe, nonradiating unilateral pain with associated nausea and vomiting. Ovarian torsion can occur in women in their reproductive-age, particularly those with a history of ovarian cysts.

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.

Group B Streptococcus (GBS) or Streptococcus agalactiae is a Gram-positive bacteria which colonizes the gastrointestinal and genitourinary tract. In the United States of America, GBS is known to be the most common infectious cause of morbidity and mortality in neonates. GBS is known to cause both early onset and late onset infections in neonates, but current interventions are only effective in the prevention of early-onset disease.

The main risk factor for early-onset GBS infection is colonization of the maternal genital tract with Group B Streptococcus during labour. GBS is a normal flora of the gastrointestinal (GI) tract, which is thought to be the main source for maternal colonization.

The principal route of neonatal early onset GBS infection is vertical transmission from colonized mothers during passage through the vagina during labour and delivery.

Intravenous penicillin G is the treatment of choice for intrapartum antibiotic prophylaxis against Group B Streptococcus.

Congenital infections can be the cause of various congenital abnormalities. Infection with the Rubella virus, part of the TORCH infections (toxoplasmosis, other organisms, rubella, cytomegalovirus, and herpes simplex), can lead to cardiac abnormalities, ophthalmic defects, sensorineural deafness and neurodevelopmental delays. At birth congenital rubella syndrome presents with a petechial rash characteristically dubbed a blueberry muffin rash, and hepatosplenomegaly with jaundice. Immunization of the mother against measles is an effective way of reducing the occurrence of congenital rubella syndrome.

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.

The most common treatment approach is with the dopamine receptor agonists, bromocriptine, and cabergoline. Bromocriptine normalizes prolactin and decreases tumour size in 80%–90% of patients with microadenomas. Bromocriptine should be given to this patient who has developed hyperprolactinemia anovulation.

Women with hyperprolactinaemic anovulation are treated with dopamine agonists such as bromocriptine.
This patient has also developed symptoms of a low-functioning pituitary gland tumour, which bromocriptine will assist to shrink. Before starting bromocriptine, a head MRI scan should be considered to confirm the suspected diagnosis.

Clomiphene is an oestrogen receptor modulator that is selective. It works by competing with oestrogen receptors in the hypothalamus. This disrupts normal negative feedback mechanisms, causing the release of pituitary gonadotropins, particularly LH, to rise, triggering ovulation.
When the levels of gonadotropins and oestrogen are normal but the women still have ovulatory dysfunction, it is successful in inducing ovulation. In hypogonadotropic hypogonadism and hypogonadotropic hypogonadism patients, clomiphene is frequently ineffective.

In eukaryotes, the genome comprises several double-stranded, linear DNA molecules bound with proteins to form complexes called chromosomes. Each species of eukaryote has a characteristic number of chromosomes in the nuclei of its cells. Human body cells (somatic cells) have 46 chromosomes.

Tetracycline is classified as a broad spectrum antibiotic. It is a bacteriostatic inhibitor of protein synthesis acting at the ribosomal level. Tetracycline binds to the 30s ribosomal subunit preventing the binding of the aminoacidic charged T-RNA to the ribosome-mRNA complex.

Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, leading to shortness of breath, dizziness, fainting, and other symptoms, all of which are exacerbated by exertion. PH in pregnancy carries a 25–56% maternal mortality rate with a mixture of intrapartum and postpartum deaths.

Current recommendations for management of PH in pregnancy include termination of pregnancy if diagnosed early, or utilizing a controlled interventional approach with early nebulized prostanoid therapy and early elective caesarean section under regional anaesthesia. Other recommended therapies for peripartum management of PH include sildenafil and nitric oxide.

The best next step in management would be to remove the cervical ectropion using cautery. This would usually be performed under anaesthesia. It can take up to a month to heal following the procedure. Vaginal pessaries and antibiotics are typically not effective.

Indications for a cone biopsy include an abnormal pap smear, lesion suspected to be a CIN on colposcopic examination that cannot be fully visualised as well if there is a histological discrepancy between the smear and biopsy. Colposcopic examination is also unnecessary at this stage since she has not complained of any abnormal per vaginal bleed nor is her last pap smear abnormal.

Since the discharge is now affecting the patient’s life, treatment should be given so reassuring her that no treatment is needed is not appropriate.

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.

Ureters are muscular tubes that run from the kidneys to the urinary bladder. It is lined by transitional epithelium.

Menstrual cycle can be divided into the follicular phase and luteal phase. In the luteal phase, there is an increase in progesterone secretion and LH levels are low. If the ova is fertilized, it is implanted in the endometrium. In case of failure in fertilization, there is gradual decrease in progesterone and LH levels.

Literature review shows that bicornuate uterus is associated with increase risk of spontaneous abortion in about 36% of patients. There is also an increased risk of preterm birth, malpresentation and fetal growth retardation.

Wound healing typically undergoes different stages that include haemostasis, inflammation, proliferation and remodelling. The phases are often shortened when healing occurs by primary intention such as in a surgical wound. Remodelling, which is the major strengthening phase, takes about 3 weeks, while it takes a total of 12 weeks to reach maximum tensile strength.

The uterus needs support in order to remain centered inside the pelvic cavity. The support it receives comes in two forms: dynamic and passive. The ligaments of the uterus have an important role in both.

Dynamic support is provided by the pelvic diaphragm through tonic contractions while standing and sitting and active contractions during moments of increased abdominal pressure, such as coughing or sneezing. During these moments, the ligaments of the uterus transmit the force of the diaphragm towards the organ itself, maintaining its position.

The ligaments are also crucial in providing passive support. By minimizing movement of the body and the cervix, they maintain the uterus in the typical anteverted and anteflexed position directly on top of the bladder. This provides a support for the uterus when the abdominal pressure increases.

Hence, even though the broad ligament, round ligament and ovarian ligament have some role in the suspension of the uterus, the uterosacral ligament plays the most significant role. It is also the ligament used for surgical suspension of POP.

Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery that is why it should be avoided.

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.

Endometriosis is a condition in which the endometrial tissue lies outside the endometrial cavity. There are 4 theories which explain this. First is pathological hyperplasia resulting in menstrual regurgitation and implantation, second is the coelomic epithelium transformation, third is immunogical factors and the fourth is via the lymphatic or vascular spread.