An endometrioma, also known as a chocolate cyst is a benign ovarian cyst that occurs as a result of the trapping of endometriosis tissue inside the ovary. The findings on transvaginal ultrasound are often a unilocular cyst, with ground glass echogenicity due to haemorrhage. Other benign masses that can be evaluated using transvaginal ultrasound are functional cysts, serous and mucinous cystadenomas and mature teratomas.

Contraindications to tocolysis in preterm labor are as follows:
– Gestational age > 34 weeks or <24 weeks
– Labor is too advanced with an advanced cervical dilation of >4 cm
– Abnormal CTG suggesting a non-reassuring fetal status
– Lethal fetal anomalies
– Intrauterine fetal demise
– Suspected fetal compromise
– Significant antepartum hemorrhage, such as placental abruption/ active vaginal bleeding with hemodynamic instability
– Any suspected intrauterine infections like chorioamnionitis
– Maternal hypotension
– Pregnancy-induced hypertension/ eclampsia/ pre-eclampsia
– Placenta previa
– Placental insufficiency
– Intrauterine growth retardation
– Maternal allergy to specific tocolytic agents or cases where tocolytics are contraindicated due to specific comorbidities like in case of cardiac disease, were beta agonists cannot be administered.

As there are nonpulmonary morbidities associated with preterm birth, fetal pulmonary maturity, known or suspected, is not an absolute contraindication for tocolysis. These fetuses could potentially benefit from prolongation of pregnancy and from the nonpulmonary benefits of glucocorticoid therapy.

When cervical dilation is greater than 3 cm inhibition of preterm labor is less likely to be successful. In such cases Tocolysis can be considered when the goal is to administer antenatal corticosteroids or to safely transport the mother to a tertiary care center.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication to suppression of labor.

A local exam might not help in locating the cause of the bleeding because it might be underneath the superficial structures. A thorough examination should be done under GA to accurately locate the source of bleeding.

Treatment for infertility caused by ovulation issues has had the best results by far. PCOS, also known as Stein-Leventhal syndrome, is marked by hyperandrogenism, tiny cysts in the ovaries, acne, and hirsutism, as well as ovulation issues that result in anovulatory cycles due to hormonal imbalance.

70% of females with anovulatory periods begin ovulation under medical supervision, and 50% of those conceive within 6 to 9 months.

Infertility can be caused by low or no sperm counts, poor sperm motility, or dysmorphic sperms. Treatment options include fertility medicines that promote sperm production, artificial insemination with donor sperm, and intracytoplasmic injection of sperm, but success rates are poor (less than 25 percent ). Following pelvic inflammatory disease, previous surgery, or tuberculosis, the Fallopian tubes become obstructed or damaged, preventing sperm from reaching the ovum. Tubal blockages and adhesions are treated by laparoscopic surgery. The success rate of conception varies greatly depending on the degree of the blockage, ranging from 10% to 70%.

Turner syndrome is linked to infertility and ovarian dysgenesis. Treatment for gonadal dysgenesis and reversal of infertility is not an option. Because of the high likelihood of miscarriages, even after egg donation, the success rate is relatively low.

The basic components of the mammary gland are the alveoli. These are lined with milk-secreting cuboidal cells surrounded by myoepithelial cells. The alveoli join to form groups known as lobules. The lobules form lobes. Each lobe has a lactiferous duct that drains into openings in the nipple. Each breast typically contains 15-20 lobes.

The chances of transmitting chlamydia from an asymptomatic partner through sexual intercourse is 65%.

The incubation period of varicella is 10-21 days.

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.

Condition where there is insufficient fetal descent after pushing for ≥3 hours in nulliparous and ≥2 hours if multiparous women is defined as Second stage arrest of labor. Common risk factors for this presentation are maternal obesity, excessive weight gain during pregnancy and diabetes mellitus. Cephalopelvic disproportion, malposition, inadequate contractions and maternal exhaustion are the common etiologies of Second stage arrest of labor. Management includes Operative vaginal delivery or cesarean delivery as indicated in the case.

The second stage of labor begins with the dilatation of cervix to 10 cm and will end with fetal delivery. Parity and use of neuraxial anesthesia are the two factors which will affect the duration of second stage of labor and fetal station, which measures the descent of the fetal head through the pelvis determines its progression.

When there is no fetal descent after pushing for ≥3 hours or ≥2 hours in in nulliparous and multiparous patients respectively the condition is called an arrested second stage of labor. As her first delivery was a cesarean session due to breech presentation, this patient in the case is considered as nulliparous.

Most common cause of a protracted or arrested second stage is fetal malposition, which is the relation between the fetal presenting part to the maternal pelvis. Occiput anterior is the optimal fetal position as it facilitates the cardinal movements of labor, any deviations from this position like in occiput transverse position, can lead to cephalopelvic disproportion resulting in second stage arrest.
Inadequate contractions, that is less than 200 MVU averaged over 10 minutes, can lead to labor arrest but contractions are adequate in case of the patient mentioned.
Second stage arrest can be due to maternal obesity and excessive weight gain during pregnancy but this patient had a normal pre-pregnancy BMI of 20 kg/m2 and an appropriate weight gain of 15.9 kg 35 lb. So this also cannot be the reason.

Maternal expulsive efforts will change the fetal skull shape. This process called as molding helps to facilitate delivery by changing the fetal head into the shape of the pelvis. Whereas prolonged pressure on head can result in scalp edema which is called as caput, presence of both molding and caput suggest cephalopelvic disproportion, but is not suggestive of poor maternal effort.

Patients with a prior history of uterine myomectomy or cesarean delivery are at higher risk for uterine rupture.  In cases of uterine rupture, the patient will present with fetal heart rate abnormalities, sudden loss of fetal station (eg, going from +1 to −3 station) along with fetal retreat upward and into the abdominal cavity through the uterine scar due to decreased intrauterine pressure. In the given case patient’s fetal heart rate tracing is category 1 and fetal station has remained 0 which are non suggestive of uterine rupture.

When there is insufficient fetal descent after pushing ≥3 hours in nulliparous patients or ≥2 hours in multiparous patients is considered as second stage arrest of labor. The most common cause of second stage arrest is cephalopelvic disproportion, were the fetus presents in a nonocciput anterior position called as fetal malposition.

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.

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

This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.

In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.

Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.

Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.

Human chorionic gonadotrophin (hCG) has thyrotrophic activity owing to subunit homology with thyroid-stimulating hormone (TSH) and maternal TSH production is suppressed during the first trimester of pregnancy, when hCG levels are highest. The TSH response to thyrotrophin-releasing hormone (TRH) is reduced during the first trimester but returns to normal after this. Thyroid binding globulin increases in the first 2 weeks of pregnancy and reaches a plateau by 20 weeks. This leads to increased production of total T3 (tri-iodothyronine) and T4 (thyroxine).

SLE is a type III hypersensitivity reaction

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

Nerve Supply: L5 to S2 via Nerve to Piriformis
Origin: Sacrum
Insertion: Greater trochanter
Action: External rotation of hip
Blood Supply: Superior and Inferior gluteal arteries and lateral sacral arteries

Vaginal atrophy (thinning of vaginal tissue): Oestrogen helps to keep this tissue healthy. After menopause, low oestrogen levels can cause your vaginal walls to become thin, dry, and inflamed. That often leads to bleeding after sex.

Vaginal atrophy is the most common cause of post menopausal vaginal bleeding.

With a normal pap smear a year ago, this patient is unlikely to develop cervical cancer.

Cervical ectropions are not common in post-menopausal women.

Endometrial cancer and cervical polyps are possible causes of postcoital bleeding, however, they are not as common as vaginal atrophy.

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.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.

Oesophageal atresia of the foetus interrupts the normal circulation of the amniotic fluid. This causes polyhydramnios and subsequent distension of the uterus impacting proper expansion of the lungs. This would explain the difficulty breathing.

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.

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.

Prothrombin time is increased in:
– Factor V deficiency
– Vitamin K deficiency (which affects factors 2,7 and 10)
– Warfarin therapy
– Severe liver failure
Protein C is an anticoagulant and deficiency results in a hyper-coagulable state with tendency towards thrombosis.

It has been found that it is possible for premenopausal hormones to persist for a period of time after attaining menopause. If one or a few ovarian follicles remain, they could produce oestrogen in response to the very elevated levels of FSH typically seen in menopause. In doing so, the woman can then bleed as a result of this physiological response. The symptoms seen in this vignette are consistent with the rise in oestrogen levels, likely due to follicular activity.

In the absence of any pathological findings such as endometrial carcinoma, this phenomenon would be the most likely cause of this post-menopausal bleed. Furthermore, it is unlikely for cervical cancer and endometrial cancer to present during the first few years following menopause. Atrophic vaginitis is unlikely to be associated with the other symptoms the patient presented with i.e. reduction in the intensity of hot flushes and breast enlargement. This patient was not stated to have any risk factors for endometrial hyperplasia such as obesity, late menopause and early menarche, which makes it a less likely diagnosis.

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimetres from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimetres.

A fundal height that measures smaller or larger than expected — or increases more or less quickly than expected — could indicate:
– Slow fetal growth (intrauterine growth restriction)
– A multiple pregnancy
– A significantly larger than average baby (fetal macrosomia)
– Too little amniotic fluid (oligohydramnios)
– Too much amniotic fluid (polyhydramnios).

The Conjoint tendon AKA Inguinal falx reinforces the posterior wall of the inguinal canal. The inguinal ligament is part of the floor.
The aponeurosis of external oblique is the major component of the anterior wall with fibres of internal oblique reinforcing the lateral part

Urge incontinence is involuntary pee loss accompanied by a strong desire to urinate. The most common cause of urge incontinence is detrusor or bladder dyssynergia, which is characterized by an involuntary contraction of the bladder during urine distension.

Bladder training, eliminating excess coffee and fluid intake, biofeedback, and pharmacological therapy are all options for treating urge incontinence. Treatment with anticholinergic medicines (oxybutynin chloride), -sympathomimetic agonists (metaproterenol sulphate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) has proven successful if conservative approaches fail.

The detrusor muscle will be relaxed by these pharmacologic drugs. Oestrogen therapy may improve urine control in postmenopausal women who are not on oestrogen replacement therapy. Kegel exercises can help women with stress urinary incontinence strengthen their pelvic musculature and improve bladder control.

Before considering invasive procedures, a cervical smear must first be performed. Antibiotics can only be given when inflammation has been confirmed and culture results have identified the organism causing the inflammation. Endometrial ablation, colposcopy and vaginal US are all invasive procedures that are not relevant in the immediate management of this patient.

Trichomoniasis is considered a sexually transmitted infection found both in men and women, and is caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. About 20-30% of women with the infection however are asymptomatic. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis during pregnancy and breastfeeding is 400-500mg of metronidazole twice daily for 5 -7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated and screened for other STIs.

The oocyte (eggs, ova, ovum) is arrested at an early stage of the first meiosis (first meiotic) division as a primary oocyte (primordial follicle) within the ovary. Following puberty, during each menstrual cycle, pituitary gonadotrophin stimulates completion of meiosis 1 the day before ovulation.