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 given case pre-pregnancy counselling and management of chronic hypertension is very much essential.
Some commonly prescribed antihypertensive drugs like ACE inhibitors, angiotensin receptor antagonists, diuretics and most beta blockers are contraindicated or is best to be avoided before conception and during pregnancy.
Methyldopa is considered as the first line drug for the management of mild to moderate hypertension in pregnancy and is the most commonly prescribed antihypertensive for this indication.
Hydralazine can be used during any hypertensive emergencies in pregnancy.
Intake of Angiotensin receptor blockers and ACE inhibitors during the first trimester can lead to complications as they are both teratogenic; use of these drugs during second and third trimesters can result in foetal renal dysfunction, oligohydramnios and skull hypoplasia.
Diuretics can cause foetal electrolyte disturbances and significant reduction in maternal blood volume.
All beta blockers, except labetalol, can result in foetal bradycardia, and growth restriction in case its long-term use.
Calcium channel antagonists, except nifedipine, are avoided during pregnancy due to its high risk for maternal hypotension and foetal hypoxia.

The pelvic outlet is bounded anteriorly by the inferior border of the pubic arch, posteriorly by the sacrotuberous ligament and the tip of the coccyx and laterally by the ischial tuberosities.

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.

With increasing maternal age, the risk of miscarriage increases. For women between the ages of 40-44, the miscarriage rates sit at about 50% and increases to over 75% for women 45 years and over. The miscarriage rate for women between the ages of 35-39 is 25%.

Placental abruption is defined as the premature separation of placenta from uterus and the condition usually presents with bleeding, uterine contractions and fetal distress. It is one of the most significant cause of third-trimester bleeding and is often associated with fetal and maternal mortality and morbidity. In all pregnant women with vaginal bleeding in the second half of the pregnancy, this condition should be considered as a differential diagnoses.
Though vaginal bleeding is the most common presenting symptom reported by almost 80% of women with placental abruption, vaginal bleeding is concealed in 20% of women with placental abruption, therefore, absence of vaginal bleeding does not exclude placental abruption.

Symptoms and complications of placental abruption varies according to patient, frequency of appearance of some common features is as follows:
‌- Vaginal bleeding is the common presentation in 80% of patients.
‌- Abdominal or lower back pain with uterine tenderness is found in 70%
‌- Fetal distress is seen in 60% of women.
‌- Abnormal uterine contractions like hypertonic, high frequency contractions are seen in 35% cases.
‌- Idiopathic premature labor in 25% of patients.
‌- Fetal death in about 15% of cases.

Examination findings include vaginal bleeding, uterine contractions with or without tenderness, shock, absence of fetal heart sounds and increased fundal height due to an expanding hematoma. Shock is seen in class 3 placental abruption which represents almost 24% of all cases of placental abruption.

Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood distributed to the intervillous spaces of the placentae, and 20 per cent to the uterine myometrium. Weight of the uterus increases from 50–60 g prior to pregnancy to 1000 g by term.

20% of the patients with breast cancer will have hypercalcemia.

The patient most likely suffered a uterine rupture. It occurs most often in multiparous women and is less often associated with external haemorrhage. Shock develops shortly after rupture due to the extent of concealed bleeding.

Uterine inversion rarely occurs when after a spontaneous and normal third stage of labour. Although it can lead to shock, it is usually associated with a history of controlled cord traction or Dublin method of placenta delivery before the uterus has contracted. This diagnosis is also strongly considered when shock is out of proportion to the amount of blood loss.

An overwhelming infection is unlikely in this case when labour occurred for a short period of time. Uterine atony and amniotic fluid embolism are more associated with excessive vaginal bleeding, which is not evident in this case.

Choriocarcinoma may arise as a complication of gestation or as spontaneous germ cell tumours. As this scenario depicts that the women has previous abortion points to the fact that these may have been molar pregnancies. As choriocarcinoma can arise from a molar pregnancy it can be differentiated from it by the presence of invasion into the uterus and metastasis to the lungs primarily.

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.

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.

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.

Breast feeding facilitates the production of Oxytocin by the hypothalamus which is stored and secreted by the posterior pituitary.
Ergometrine is an ergoline derivative that can be used to increase uterine tone.
Atosiban is an antagonist of Oxytocin receptors
ADH is another posterior pituitary hormone.
Prostaglandin E2 plays an important role in cervical ripening.

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.

Syntocin 5u by slow intravenous injection is the first line pharmacological measurement in this scenario

In the foetus, the hypogastric artery ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

Turner syndrome, a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects. Streak ovaries are a form of ovarian dysgenesis and are associated with Turner syndrome. Occasionally they may be functional and secondary sexual characteristics may develop.

Some confusion regarding breast cancer screening arose in 2009 when the U.S. Preventive Services Task Force (USPSTF) issued new mammogram guidelines. The task force recommended that screening mammograms be conducted every two years, beginning at age 50, for women with an average risk of breast cancer. For women aged 40 to 49, the decision of whether to have annual mammograms should be based on a patient’s consideration of risks vs. benefits, according to the task force.

There is no evidence that frequent screening for women on HRT helps with early detection of malignancy.

Normal menstrual blood loss is about 40-45 ml. More than 80 ml per period is defined as heavy menstrual bleeding.

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.

Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management.

Absolute contraindications to endometrial ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In general, endometrial ablation should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm).

Evidence is not yet of sufficient quality for there to be evidence-based guidelines or recommendations. Having excluded other causes:

Reassure patients that breakthrough bleeding is a common side-effect of CHC and usually resolves after three cycles of use.
Advise women who smoke that stopping smoking may improve cycle control.
If bleeding persists after three cycles, consider changing formulation:
Increase dose of oestrogen, particularly if on a 20-microgram ethinylestradiol (EE) preparation

All other options are not acceptable.

Postpartum haemorrhage (PPH) is a cumulative blood loss greater than 1000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery.

The first step in managing hemorrhagic shock is recognition. This should occur before the development of hypotension. Close attention should be paid to physiological responses to low blood volume. Tachycardia, tachypnoea, and narrowing pulse pressure may be the initial signs.

Tachycardia is typically the first abnormal vital sign of hemorrhagic shock. As the body attempts to preserve oxygen delivery to the brain and heart, blood is shunted away from extremities and nonvital organs. This causes cold and modelled extremities with delayed capillary refill. This shunting ultimately leads to worsening acidosis.

Neisseria Gonorrhoeae is a Gram negative diplococci.

The clinical features of endometriosis include dyspareunia, dysmenorrhea, dysuria, dyschezia as well as infertility. Pain is characteristically long-term, cyclic (often occurring the same time as menses) and can get progressively worse over time. Laparoscopy remains the standard for diagnosis. There are many cases in which endometriosis is only discovered at the time of the workup for infertility.

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.

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.

Anaemia in pregnancy is most frequently caused by iron or folate deficiency, however, a wide variety of other causes may be considered, especially if the haemoglobin value is below 9.0 g/dL. A haemoglobin level of 11 g/dL or more is considered normal early in pregnancy, with the upper limit of the ‘normal range’ dropping to 10.5 g/dL by 28 weeks gestation. Haemoglobin < 10.5 g/dl in the antenatal period, one should exclude haemoglobinopathies and consider haematinic deficiency. Oral iron is 1st line treatment for iron deficiency. Anaemia not due to haematinic deficiency will not respond to any form of iron. This should be managed with transfusion

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.