Yasmin has been linked to decreased fluid retention and weight gain as a side effect of COCs, which is why most women who experience this side effect prefer Yasmin®.
Due to its anti-mineralocorticoid properties, drospirenone, unlike earlier progestogens, is associated with no weight gain or even moderate weight loss.
Yasmin has a similar failure rate to other COCs. No evidence using Yasmin is linked to a lower risk of cervical cancer as a long-term side effect of COCs. Yasmin, like all COCs, can cause spotting and irregular bleeding in the first few months of use.
Drospirenone, a progesterone component, has antiandrogenic properties and is slightly more successful in treating acne, but the difference is not big enough to make it preferable in terms of acne therapy or prevention when compared to other COCs.

The superior mesenteric vein joins the splenic vein to form the hepatic portal vein.

Opiates and spinal anaesthetics reduce the variability of a CTG. Including some antihypertensives like labetalol and alpha methyl dopa.

Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.

Dehydroepiandrosterone (DHEA) is a steroid hormone synthesised from cholesterol (via Pregnenolone) by the adrenal glands. The foetus manufactures DHEA, which stimulates the placenta to form oestrogen, thus keeping a pregnancy going. Production of DHEA stops at birth, then begins again around age seven and peaks when a person is in their mid-20s

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges.

As the mother is found to be rhesus negative while her baby being rhesus positive, the given case is clinically diagnosed as spontaneous abortion due to Rh incompatibility. The mother should be administered anti-D for prophylaxis for avoiding future complications.

Rhesus (Rh) negative women who deliver a Rh-positive baby or who comes in contact with Rh positive red blood cells are at high risk for developing anti-Rh antibodies. The Rh positive fetuses
eonates of such mothers are at high risk of developing hemolytic disease of the fetus and newborn, which can be lethal or associated with serious morbidity.
In such situations both spontaneous and threatened abortion after 12 weeks of gestation, are indications to use anti-D in such situations.

All the other options are incorrect.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

Radiotherapy works on the principle of ionisation. In particularly that of water leading to the formation of free radicals, these radicals are highly reactive and they react with the DNA leading to damage and cell death.

Breakthrough bleeding, or spotting, refers to when vaginal bleeding occurs between menstrual cycles. It may look like light bleeding or brown discharge.

Spotting is the most common side effect of birth control pills. It happens because the body is adjusting to changing levels of hormones, and the uterus is adjusting to having a thinner lining.

Taking the pill as prescribed, usually every day and at the same time each day, can help prevent bleeding between periods.

All other options are incorrect as this is a common side effect and will resolve on its own.

Incoordinate uterine action almost always results in fetal distress due to increased resting intrauterine pressure. All other statements can also cause fetal distress, however, these are not as common as incoordinate uterine action. Syntocin infusion for labour augmentation and administration of epidural anaesthetic for pain relief can also increase the risk of fetal distress.
Cardiotocograph (CTG) monitoring during labour is highly recommended in patients where the fetal head is found in the OP position. Moreover, it is mandatory when there is Syntocin infusion or epidural anaesthesia.

A rare complication of pelvic inflammatory disease is Fitz Hugh Curtis syndrome which is perihepatitis leading to the formation of adhesions between the liver and the peritoneal surface. It is most commonly caused by chlamydia and gonorrhoea. Ophthalmia neonatorum is conjunctivitis which is also caused by these pathogens.

A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK. An inevitable miscarriage occurs with the usual symptoms of a miscarriage such as menstrual-like cramping, vaginal bleeding and a dilated cervix. The gestational sac has ruptured but products of conception have not been passed. The products of conception will eventually pass.

A missed miscarriage is described as a loss of pregnancy without vaginal bleeding, loss of tissue, cervical changes or abdominal pain. During a scan, a fetal heartbeat is not observed, and the gestational sac may be small.

A threatened miscarriage is when the cervix dilates and uterine bleeding is seen; the pregnancy could still be viable.

A complete miscarriage occurs when all the products of conception are expelled from the uterus, bleeding has stopped, and the cervix has closed up after dilation. Recurrent miscarriages are described as spontaneous pregnancy loss of more than 2 to 3 consecutive times.

Approximately 75–80% of patients with PCOS will ovulate after Clomiphene citrate. Although there appears to be discrepancy between ovulation and pregnancy rates, life-table analysis of the largest and most reliable studies indicates a conception rate of up to 22% per cycle in those ovulating on CC.

Pelvic TB causes tubal occlusion by scarring leading to infertility. Once occlusion occurs, IVF is usually the only option for conception. This is also the case for women with Turner syndrome.

Azoospermia maybe treated with surgery or hormonal therapy based on the cause but the success rate is low.

Overflow incontinence typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying. Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia. When the bladder is very full, stress leakage can occur or low-amplitude bladder contractions can be triggered resulting in symptoms similar to stress or urgency incontinence.

Women with urgency incontinence experience the urge to void immediately preceding or accompanied by involuntary leakage of urine

Individuals with stress incontinence have involuntary leakage of urine that occurs with increases in intraabdominal pressure (e.g., with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction.

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

Nuchal translucency scans and maternal screening tests simply aid in determining a risk percentage for the presence of Trisomy 21, but an accurate diagnosis cannot be reached.

Chorionic villous biopsy (CVB), amniocentesis, and cordocentesis, are all prenatal diagnostic tests that can provide a definitive diagnosis regarding the presence of foetal abnormalities.

Amniocentesis performed at 16 weeks of gestation is associated with the lowest risk for miscarriage and hence is the safest test and should be recommended to the mother (correct answer).

The miscarriage risk from a CVB is at least double the risk following amniocentesis.

Nowadays, cordocentesis is rarely used for sampling of foetal material to detect chromosomal abnormalities as the test poses an even higher risk of miscarriage compared to the other procedures discussed above.

Varicella is a live vaccine. The recent RCOG green top guidelines suggest vaccine can be considered postpartum or pre pregnancy but NOT whilst pregnant. In the non-immune pregnant woman they should be advised to avoid contact with people with chickenpox or shingles and to contact a healthcare professional promptly if exposed. If they have a significant exposure VZIG should be offered as soon as possible.

Sertoli cells contain receptors for FSH. In response to this Sertoli cells synthesize inhibin, androgen binding proteins and anti Mullerian hormone all which are connected to the reproduction cycle.

This patient is most likely to have a ruptured ectopic pregnancy. The history of multiple TOPs suggests her contraceptive methods are not reliable and her missed period is suggestive she may currently be pregnant. There is no temperature or vaginal discharge to suggest PID though this is of course possible as is appendicitis. The last termination was 6 months ago so endometritis is unlikely.

The gestational sac can be visualized from as early as 4–5 weeks of gestation and the yolk sac at about 5 weeks (Figure 6.3). The embryo can be observed and measured at 5–6 weeks gestation.

The luteinizing hormone (LH) surge during ovulation causes: Increases cAMP resulting in increased progesterone and PGF2 production PGF2 causes contraction of theca externa smooth muscle cells resulting in rupture of the mature oocyte

Due to the previous history of caesarean section, uterine rupture would be the most likely cause of bleeding in this patient who is at a prolonged active phase of first stage of labour.

Maternal manifestations of uterine rupture are highly variable but some of its common features includes:
– Constant abdominal pain, where the pain may not be present in sufficient amount, character, or location suggestive of uterine rupture and may be masked partially or completely by use of regional analgesia.
– Signs of intra abdominal hemorrhage is a strong indication. Although hemorrhage is common feature, but signs and symptoms of intra-abdominal bleeding in cases of uterine rupture especially in those cases not associated with prior surgery may be subtle.
– Vaginal bleeding is not considered as a cardinal symptom as it may be modest, despite major intra-abdominal hemorrhage.
– Maternal tachycardia and hypotension
– Cessation of uterine contractions
– Loss of station of the fetal presenting part
– Uterine tenderness
As seen in this case, fetal bradycardia is the most common and characteristic clinical manifestation of uterine rupture, preceded by variable or late decelerations, but there is no other fetal heart rate pattern pathognomonic of rupture. Furthermore, fetal heart rate changes alone have a low sensitivity and specificity for diagnosing a case as uterine rupture.
Pain and persistent vaginal bleeding despite the use of uterotonic agents are characteristic for postpartum uterine rupture. If the rupture extends into the bladder hematuria may also occur.
A definite diagnosis of uterine rupture can be made only after laparotomy. Immediate cesarean section should be performed to save both the mother and the baby in cases where uterine rupture is suspected.

Sodium Valproate is known to be the most teratogenic when used in the first trimester of pregnancy. This antiepileptic increases the risk of congenital malformations including a 10-20 fold risk of neurodevelopmental defects. Though the use of antiepileptics should generally be avoided during pregnancy, carbamazepine, or newer drugs such as Lamotrigine are thought to carry less of a risk of teratogenicity.

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.

Progestin only pills increase the risk of developing follicular cysts. Sonographic studies have observed that follicular cysts are more common in POP users than women not using hormones. The follicular changes tend to increase and regress over time. No intervention is required in asymptomatic women, other than reassurance. POP users who have persistent concerns about ovarian follicular changes should be offered another method of contraception.

All other options are not contraindications to the use of mini-pills.

Pelvic organ prolapse is a common condition amongst ageing women where a weakness in the pelvic support structures of the pelvic floor allows pelvic viscera to descend.
The Pelvic Organ Prolapse Quantification system (POP-Q) is useful for describing and staging the severity of the pelvic organ prolapse.
Grade 1: the most distal portion of the prolapse is more than 1 cm above the level of the hymen
Grade 2: the most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Grade 3: the most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (for example, not all of the vagina has prolapsed)
Grade 4: vaginal eversion complete

Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement.

The most likely cause of her postcoital bleeding is cervical ectropion as suggested by her postcoital bleeding, normal pap smears and use of oral contraceptive pills.

Cervical ectropion is a benign condition that occurs as a result of overexposure to oestrogen. Here, glandular cells (the columnar epithelium) lining the endocervix, begin to grow on the ectocervix, leading to exposure of the columnar cells to the vaginal environment.

These columnar cells are prone to trauma and bleeding during coitus.

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.