Abruptio placentae, defined as a premature separation of the placenta from the uterine wall, is commonly seen with blunt abdominal trauma and can cause fetal distress. It occurs in 1% to 3% of pregnant women with minor trauma and in 40% to 50% with major life-threatening trauma.8,9 Abruption may present with vaginal bleeding, abdominal pain and tenderness, uterine contractions, or fetal distress; however, it may be occult with no vaginal bleeding in up to 20% of cases.

After perineal repair, lactulose and a bulking agent should ideally be given for 5-10 days as well as broad spectrum antibiotics should be given that will cover all possible anaerobic bacteria. At 6-12 months a full evaluation should be done regarding the progress of healing. 60 to 80% of women are asymptomatic 12 months post delivery and external anal sphincter repair.

The pubic symphysis or symphysis pubis is the midline cartilaginous joint (secondary cartilaginous) uniting the superior rami of the left and right pubic bones. It is located anterior to the urinary bladder and superior to it.

Bacterial vaginosis is a common infection of the vagina caused by the overgrowth of atypical bacteria, most commonly Gardnerella vaginalis, a gram indeterminate bacteria, which is also a facultative anaerobe. Patients often complain of foul-smelling fishy discharge and dysuria. In diagnosing BV, a swab is taken for microscopy, often revealing clue cells. Of the other organisms listed in the options, Neisseria is an obligate anaerobe, while Chlamydia trachomatis is an obligate intracellular aerobe. Treponema Pallidum is an aerophilic bacteria and Mycoplasma hominis is a pleomorphic parasitic bacterium.

Cord entanglement, a condition unique to MoMo pregnancies, occurs in 42 to 80% of the cases and it has been traditionally related to high perinatal mortality. Umbilical cord entanglement is present in all monoamniotic twins when it is systematically evaluated by ultrasound and colour Doppler. Perinatal mortality in monoamniotic twins is mainly a consequence of conjoined twins, twin reversed arterial perfusion (TRAP), discordant anomaly and spontaneous miscarriage before 20 weeks’ gestation. Expectantly managed monoamniotic twins after 20 weeks have a very good prognosis despite the finding of cord entanglement. The practice of elective very preterm delivery or other interventions to prevent cord accidents in monoamniotic twins should be re-evaluated.

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.

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

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.

Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.

Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.

BV recurrence rates are high, approximately 80% three months after effective treatment.

The history is typical of Intrahepatic Cholestasis of Pregnancy, also known as obstetric cholestasis and prurigo gravidarum. It is characterised by itching without rash and abnormal LFTs beyond normal pregnancy ranges. Itching affects around 23% of pregnancies and can occur before biochemical changes.

Gonadotropin-releasing hormone (GnRH) is the hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.

The best next step in her management is a colposcopy.

Patients diagnosed with high-grade lesions (CIN 2 or 3) or adenocarcinoma in situ (AIS) during pregnancy should undergo surveillance via colposcopy and age-based testing (cytology/HPV) every 12-24 weeks.

Cone biopsy and long loop excision of the transformation zone (LLETZ biopsy) are not recommended if the lesion extends up the canal and out of the vision of the colposcope.
It is not necessary to terminate the pregnancy.

Because repeat colposcopic examination during pregnancy offers all of the information needed, the repeat Pap smear is best done after the pregnancy has ended.

Unless colposcopy indicates aggressive cancer at an earlier time, the ultimate therapy required is usually not decided until the postpartum visit.

In a person who is infected by streptococcus (Group B) should be started on benzylpenicillin as soon as possible. In case of allergy vancomycin should be started at 1g every 12 hours. Tetracyclines should be avoided in pregnancy.

Menorrhagia in a 45-year-old woman is most likely caused by an ovulation issue, most likely anovulatory cycles, particularly if the periods have grown irregular.

Endometrial carcinoma is a rare cause of menorrhagia that usually occurs after menopause.

Menorrhagia can be caused by fibroids, endometrial polyps, and adenomyosis, although the cycles are normally regular, and a dramatic change from normal cycles six months prior would be exceptional.
If fibroids or adenomyosis are the source of the menorrhagia, the uterus is usually enlarged.

At the 36‑week appointment, all pregnant women should be seen again. At this appointment: measure blood pressure and test urine for proteinuria; measure and plot symphysis–fundal height; check position of baby; for women whose babies are in the breech presentation, offer external cephalic version (ECV)

Remember the inferior rectal artery supplies the anus. The middle rectal artery is the principle supply to the lower 1/3 rectum. The rectal arteries do form an anastomosis.

Cilia are small hair line projections in the fallopian tube. Their main function is to transport the egg through he fallopian tube towards the uterus. It is present in many other tubular organs and its function varies accordingly to the organ.

For a diagnosis of Preeclampsia to be established, hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week should be present.

Oxytocin is responsible for the let down mechanism that occurs during breast feeding in which the myothelial cells contract and push the milk into the ductules.

Uterine surgical history & scope of vaginal birth are as follows:
– In case of low transverse cesarean delivery with horizontal incision: trial of labor is not contraindicated.
– Classical cesarean delivery with vertical incision: trial of labor is contraindicated
– Abdominal myomectomy with uterine cavity entry: trial of labor is contraindicated
– Abdominal myomectomy without uterine cavity entry: trial of labor is not contraindicated.

In laboring patients with prior uterine surgical histories like a prior classical (vertical) cesarean delivery or a prior myomectomy that was extensive or has entered the uterine cavity like during removal of intramural or submucosal fibroids are at a higher risk for uterine rupture. Given this patient’s history of previous myomectomy, her intense and constant abdominal pain with an abnormal fetal heart rate tracing, like persistent variable decelerations, are pointing to uterine rupture. vaginal bleeding, abdominally palpable fetal parts, loss of fetal station and any change in contraction pattern are the other possible manifestations of uterine rupture. Based on the extent and exact location of the rupture and the presence or absence of regional anesthesia, presentation of a uterine rupture will change.

Vaginal delivery is safe after a low transverse (horizontal uterine incision) cesarean delivery. Patients with a history of either classical cesarean delivery or an extensive myomectomy are delivered via cesarean delivery at 36-37 weeks gestation, so urgent laparotomy and cesarean delivery are required if these patients present in labor. Further management is determined by other intraoperative findings like, whether uterine rupture has occurred, if occured then delivery is done through the rupture site, followed by a uterine repair; If the uterus is unruptured, a hysterotomy (ie, cesarean delivery) is performed. In patients with prior classical cesarean delivery or extensive myomectomy, an expectant management for a vaginal delivery is contraindicated.

Amnioinfusion is the technique of placing an intrauterine pressure catheter to decrease umbilical cord compression by doing an intrauterine infusion and this thereby helps to resolve variable decelerations. In patients with a history of uterine surgery Amnioinfusion is contraindicated.

In cases with abnormal fetal heart rate tracings, if the patient is completely (10cm) dilated, an operative vaginal delivery can be performed to expedite a vaginal delivery.

Terbutaline is a tocolytic, which is administered to relax the uterus in conditions with contractile abnormalities, such as tachysystole which presents with >5 contractions in 10 minutes or tetanic contractions were contractions last for >2 minutes, which results in fetal heart rate abnormalities. In the given case, the patient’s contractions are normal, which occurs in every 2-3 minutes and lasts for 45 seconds, causing pain and cervical dilation.

After a classical cesarean delivery or an extensive myomectomy, labor and vaginal delivery are contraindicated due to its significant risk of uterine rupture. Laparotomy and cesarean delivery are preferred in laboring a patients at high risk of uterine rupture.

Klinefelter syndrome is associated with testicular atrophy, eunuchoid body shape, tall, long extremities, female hair distribution and gynaecomastia. It is a common cause of hypogonadism seen during fertility workup.

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

Absolute contraindications to OCs include breast cancer, history of deep venous thrombosis or pulmonary embolism, active liver disease, use of rifampicin, familial hyperlipidaemia, previous arterial thrombosis, and pregnancy, while relative contraindications include smoking, age over 35, hypertension, breastfeeding, and irregular spontaneous menstruation.

Dinoprostone is associated with a transient pyrexia. This typically normalises within 4 hours of stopping treatment

Turner syndrome is the clinical diagnosis for this patient. Turner syndrome affects women who are lacking all of one X chromosome (45, characterized by X gonadal dysgenesis).
Turner Syndrome is characterized by small stature and non-functioning ovaries, resulting in infertility and lack of sexual development. Other sexual and reproductive organs (uterus and vagina) are normal despite the inadequate or missing ovarian activity.

Webbing of the neck, puffy hands and feet, coarctation of the aorta, and cardiac anomalies are all physical symptoms of Turner Syndrome. Streak gonads are also a feature of Turner syndrome.

The ovaries are replaced with fibrous tissue and do not produce much oestrogen, resulting in amenorrhea.

Until puberty, when oestrogen-induced maturation fails, the external female genitalia, uterus, and fallopian tubes develop normally.

In early pregnancy Progesterone is produced by the corpus luteum.. This organ is fundamental for pregnancy maintenance until the placenta (syncytiotrophoblast) takes over its function at the 7-9th week of gestation, just after the expression of major histocompatibility complex antigens is suppressed in extra-embryonic fetal tissue.

Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.

The Inguinal Canal
– Anterior wall: formed by the external oblique aponeurosis throughout the length of the canal; its lateral part is reinforced by muscle fibres of the internal oblique.
– Posterior wall: formed by the transversalis fascia; its medial part is reinforced by pubic attachments of the internal oblique and transversus abdominis aponeuroses that frequently merge to variable extents into a common tendon—the inguinal falx (conjoint tendon)—and the reflected inguinal ligament.
– Roof: formed laterally by the transversalis fascia, centrally by musculo-aponeurotic arches of the internal oblique and transversus abdominis, and medially by the medial crus of the external oblique aponeurosis.
– Floor: formed laterally by the iliopubic tract, centrally by gutter formed by the infolded inguinal ligament, and medially by the lacunar ligament.

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.

Functional Hypothalamic Amenorrhea (FHA) is a form of chronic anovulation, due to non-identifiable organic causes and often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic aetiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone density loss and infertility.

Abnormal uterine bleeding is a relatively common disorder which may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.

Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problem or for older women. Oestrogen would only increase the problem, which is usually due to anovulation with prolonged oestrogen secretion, producing a hypertrophic endometrium.