This question is about the differential diagnoses that should be considered if a patient presents with postpartum fever. The work-up for such patients would usually involve vaginal swabs, midstream urine culture and sensitivity and an ultrasound scan of the wound to look for any presence of a haematoma. LSCS is a major surgery and one common cause of puerperal fever would be surgical site infection. It is not surprising that women who deliver via LSCS are at higher risk of developing post-partum fever compared to those who deliver vaginally. Other common causes include endometritis and UTI. Ultrasound examination of the pelvic deep venous system and the legs would also be done to look for any thrombosis. Deep vein thrombosis can occur due to immobility, however it is unlikely to present with fever.

The best treatment option for chlamydial urethritis in pregnancy is Azithromycin 1g as a single dose orally. This is the preferred option as the drug is coming under category B1 in pregnancy.

Tetracycline antibiotics, including doxycycline, should never be used in pregnant or breastfeeding women.

Erythromycin Estolate is contraindicated in pregnancy due to its increased risk for hepatotoxicity. Ciprofloxacin is not commonly used for treating chlamydial urethritis and its use is not safe during pregnancy.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

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

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.

The middle rectal artery arises from the anterior division of the internal iliac artery.

Bicornuate uterus is associated with an increased chance of urinary tract anomalies. Urinary tract anomalies were present in about 23.6% of cases of bicornuate uterus patients.

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.

The production of milk is regulated by the hormone Prolactin. Oxytocin on the other hand is responsible for the let down reflex that occurs during breast feeding.

The Mantoux test is based on type IV hypersensitivity reaction.

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.

Neisseria Gonorrhoeae is a Gram negative diplococci.

The average volume of uterine blood flow at term is 500-750 ml/min.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a non-stress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

Disseminated intravascular coagulation (DIC) in pregnancy is the most common cause of an abnormal haemorrhage tendency during pregnancy and the puerperium. Although pregnancy itself can cause DIC, its presence is invariably evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead foetus, amniotic fluid embolism, placental retention or bacterial sepsis.

Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

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.

Skin signs during pregnancy may include: dark spots on the breasts, nipples and inner thighs, melasma (chloasma), linea nigra, stretch marks, acne, spider telangiectasis and varicose veins.

Prostaglandins are involved in the uterine contraction and cervical dilatation during labour. Higher prostaglandin concentrations can also lead to severe menstrual cramps.

With the high level of sensitivity and specificity of current tests to measure hCG in serum and urine, pregnancy can now be diagnosed before the time of the first missed menstrual period- For current serum hCG assays, the low threshold for detection is 10-25 IU/L, while for urine assays it is 25-50 IU/L, which corresponds to approximately the seventh day after conception. Because the levels of hCG in the blood and urine are very similar, the tests are equivalent. Urine testing may reveal a positive result as early as 3-4 days after implantation. By the time of the expected menstrual period, the test will be positive 98% of the time- If a test is negative more than 1 week after the expected time of the menstrual period, it is almost certain the patient is not pregnant. To cover these rare instances where a woman has a low hCG and conceived later than expected, the test should be repeated in 1 week for a definitive result.

Since ectopic pregnancy is not a life-threatening problem for the mother until 2 months after conception, a patient with a negative urine hCG does not require ultrasonography to exclude ectopic pregnancy. Patients with a suspected ectopic pregnancy and a negative urine hCG should be followed closely, as early laparoscopic intervention can improve the chances of future fertility.

Nipple stimulation during breastfeeding triggers the production of oxytocin from the hypothalamus and its subsequent release from the posterior pituitary gland. The hormone causes the myoepithelial cells of the breast to contract causing milk to flow through the ducts.

Ergometrine and Prostaglandin E2 are used during labour to control uterine bleeding after delivery, or ripen the cervix, while Atosiban is an oxytocin antagonist.

Antidiuretic hormone is also released from the posterior pituitary, and acts on the kidneys to decrease fluid excretion.

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

Classically, hirsutism has been considered a marker of increased androgen levels in females from increased production of androgens (i.e. testosterone) either by the adrenals or due to an ovarian disease. The ovarian causes for hyperandrogenism are polycystic ovarian syndrome (PCOS) and ovarian tumours. Adrenal causes include Cushing’s syndrome, androgen-producing tumours, and congenital adrenal hyperplasia (CAH), most commonly due to 21-hydroxylase deficiency. Less common causes include the hyperandrogenic-insulin resistant-acanthosis nigricans syndrome (HAIRAN). Hyperprolactinemia by increasing adrenal dehydroepiandrosterone sulphate (DHEA-S) production may cause hirsutism. Androgenic drugs are also an important cause of hirsutism. About 20% of the patients may present with idiopathic hirsutism (IH) with normal androgen levels and ovarian function. The cause of increased hair in these women is thought to be related to disorders in peripheral androgen activity. Onset of IH occurs shortly after puberty with slow progression. PCOS and IH account for 90% of the hirsutism in women. Hirsutism can also occur in some premenopausal women and continue for a few years after menopause. This is due to decrease in ovarian oestrogen secretion with continuous androgen production.

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.

Complete abortion is defined as a ‘complete’ passage of all conception products.

The first day of the last menstrual period and findings on any prior ultrasounds should be determined to establish the gestational age and location of the pregnancy. An abdominal exam should be performed to assess for peritoneal signs that might indicate a ruptured ectopic pregnancy or extra-uterine extension of a septic abortion. Lastly, a pelvic exam is central to the evaluation of suspected miscarriage. It should include both speculum-facilitated visualization of the cervix and a bimanual examination to assess for cervical motion tenderness that may indicate a septic abortion or an adnexal mass that may herald ectopic pregnancy.

Early pregnancy loss takes many different forms. In missed abortion, there is asymptomatic or ‘missed’ death of the embryo or foetus without sufficient uterine contractions to push out the products of conception. In contrast, threatened abortion is characterized by symptomatic, ‘threatened’ expulsion of the products of conception, yet the cervical os remains closed, and the embryo or foetus remains viable.

Although there is a lack of consensus, complete abortion is often defined as the absence of a gestational sac on ultrasound with an endometrial stripe thickness of less than 30 mm.

Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and oestrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis. A woman is diagnosed with polycystic ovaries (as opposed to PCOS) if she has 20 or more follicles in at least 1 ovary. The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following:
Hirsutism
Infertility
Obesity and metabolic syndrome
Diabetes
Obstructive sleep apnoea

Drugs used in the treatment of polycystic ovarian syndrome (PCOS) include metformin (off-label use), spironolactone, eflornithine (topical cream to treat hirsutism), and oral contraceptives. Oral contraceptives containing a combination of oestrogen and progestin increase sex hormone–binding globulin (SHBG) levels and thereby reduce the free testosterone level. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels are also suppressed. This restores cyclic exposure of the endometrium to oestrogen-progestin, with the resumption of menstrual periods and decreased hirsutism.

Drug of choice for treatment of PCOS are COCs, all other options are incorrect.

Ventilation begins to increase significantly at around 8 weeks of gestation, most likely in response to progesterone-related sensitization of the respiratory centre to carbon dioxide and the increased metabolic rate. Significant alterations occur in the mechanical aspects of ventilation during pregnancy. Minute ventilation (or the amount of air moved in and out of the lungs in 1 minute) is the product of tidal volume and respiratory rate and increases by approximately 30–50 per cent with pregnancy. The increase is primarily a result of tidal volume, which increases by 40 per cent (from 500 to 700 mL), because the respiratory rate remains unchanged. The increase in minute ventilation is perceived by the pregnant woman as shortness of breath, which affects 60–70 per cent of women. This physiological dyspnoea is usually mild and affects 50 per cent of women before 20 weeks gestation, but resolves immediately postpartum.

A type II deceleration is due to placental insufficiency which can result in fetal distress and asphyxia. The fetal heart rate is lowest at the start of the contraction and returns to normal after the contraction is complete.

An ectopic pregnancy is definitely present in this patient. An extrauterine pregnancy is referred to as an ectopic pregnancy. The fallopian tube accounts for 96% of ectopic pregnancies, but other sites include the cervical, interstitial (also called cornual; a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus), hysterotomy (caesarean) scar, intramural, ovarian, or abdominal. Furthermore, multiple gestations may be heterotopic in rare situations (including both a uterine and extrauterine pregnancy). Diabetes mellitus is not considered a risk factor for the development of an ectopic pregnancy.

Risk factors for ectopic pregnancy are summarized below:
High Risk: (Risk factors & Odds ratio)
Previous ectopic pregnancy 2.7 to 8.3
Previous tubal surgery 2.1 to 21
Tubal pathology 3.5 to 25
Sterilization 5.2 to 19
IUD – Past use 1.7 – Current use 4.2 to 16.4
Levonorgestrel IUD 4.9
In vitro fertilization in current pregnancy 4.0 to 9.3

Moderate:
Current use of oestrogen/progestin oral contraceptives 1.7 to 4.5
Previous sexually transmitted infections (gonorrhoea, chlamydia) 2.8 to 3.7
Previous pelvic inflammatory disease 2.5 to 3.4
In utero diethylstilbesterol (DES) exposure 3.7
Smoking – Past smoker 1.5 to 2.5 – Current smoker 1.7 to 3.9
Previous pelvic/abdominal surgery 4.0
Previous spontaneous abortion 3.0

Low:
Previous medically induced abortion 2.8
Infertility 2.1 to 2.7
Age ≥40 years 2.9
Vaginal douching 1.1 to 3.1
Age at first intercourse <18 years 1.6
Previous appendectomy 1.6

Leiomyomas uterine (fibroids)
Clinical features:
Menses that are heavy and last a long time, symptoms of pressure, pelvic discomfort, constipation, frequency of urination, complications during pregnancy, fertility problems, loss of pregnancy, premature birth, uterus enlargement and irregularity

Workup:
Ultrasound

Treatment:
Asymptomatic: monitoring
Surgical intervention, hormonal contraception

This patient has uterine leiomyomata, or fibroids, which are benign smooth muscle (myometrial) tumours that are very prevalent in adult women (up to 25%). These tumours can expand the endometrium’s surface area, the uterus’ overall size and thickness, and compress adjacent structures; nevertheless, some individuals have no symptoms and are identified by chance during a physical examination or imaging (as in this patient’s CT scan after a car accident).
Heavy, prolonged menses are among the indications for uterine leiomyomata treatment (particularly if associated with anaemia).
Pelvic discomfort that persists (e.g., dyspareunia).
Symptoms in abundance (e.g., pelvic pressure, hydronephrosis, constipation).
Recurrent miscarriages.
Medical or surgical treatment options are available for patients with these clinical characteristics (e.g., myomectomy).

This woman had mild menses and no pelvic discomfort or mass symptoms while having many big intramural and pedunculated leiomyomata (e.g., no ureter compression). There is no need for extra treatment in persons with asymptomatic fibroids. Only observation and reassurance are required.
In the treatment of symptomatic fibroids, a combination of oral contraceptive pills and progestin-containing intrauterine devices can be utilised, although they are not required in the management of asymptomatic fibroids. Furthermore, this patient has a minimal risk of unwanted pregnancy (e.g., monogamous, same-sex relationship), and the hazards of these contraceptives (e.g., venous thromboembolism, uterine perforation) outweigh the benefits.

GnRH agonist therapy (e.g., leuprolide) is a treatment for symptomatic uterine fibroids that works by inhibiting pulsatile FSH and LH production in the hypothalamus, lowering oestrogen levels. Low oestrogen levels cause a temporary reduction in leiomyoma size, which helps with heavy menses and bulky symptoms. Because long-term usage of GnRH agonists is linked to an increased risk of osteoporotic fractures, they are only administered preoperatively.

Tranexamic acid is a nonhormonal medicinal medication that reduces heavy menstrual bleeding by preventing fibrin breakdown (i.e., an antifibrinolytic drug). This patient’s menses are light.
Uterine leiomyomata (fibroids) are benign myometrial tumours that can produce a range of symptoms but are often identified by chance. Heavy menstrual blood, pelvic pain, and bulk symptoms are all indications for treatment. Patients with asymptomatic fibroids merely need to be monitored and reassured.

These are the six routine blood tests that every mum-to-be has to undergo around week 7 of pregnancy: Full Blood Count, Blood Typing, Hepatitis B Screening, Syphilis Screening, HIV Screening and Oral Glucose Tolerance Test (OGTT)

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.

Engagement means when the fetal head enters the pelvic brim/inlet and it usually takes place 2 weeks before the estimated delivery date i.e. at 38 weeks of pregnancy.

An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary. Although the discovery of an ovarian cyst causes considerable anxiety in women owing to fears of malignancy, the vast majority of these lesions are benign.

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

However, meta-analyses have since shown that there is no difference between OCP use and placebo in terms of treatment outcomes in ovarian cysts and that these masses should be monitored expectantly for several menstrual cycles.

If a cystic mass does not resolve after this timeframe, it is unlikely to be a functional cyst, and further workup may be indicated.

Other methods of management maybe revisited if cyst increases in size or becomes complex upon follow up.

Paroxetine is an SSRI used for hot flushes in women with contraindication for hormonal therapy.

Hormonal or other pharmacotherapy is usually needed for women with bothersome hot flashes. For most women with moderate to very severe hot flashes and no contraindications, we suggest MHT. Women with an intact uterus need both oestrogen and a progestin, while those who have undergone hysterectomy can receive oestrogen only. For women interested in MHT, the first step is to determine the potential risks for the specific individual.

The majority of perimenopausal and recently menopausal women are good candidates for short-term hormone therapy for symptom relief. However, for women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event (VTE) or stroke, or those at moderate or high risk for these complications, alternatives to hormone therapy should be suggested. For women with moderate to severe hot flashes who are not candidates for hormone therapy based upon their breast cancer, CHD, or VTE risk and for those who choose not to take MHT, we suggest nonhormonal agents. The agents most commonly used include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs.

Black Cohosh is found to be no more significant than placebo.
Long-term use of mefenamic acid is controversial and not recommended.

The gestational sac is typically visible from 31 days gestation by transvaginal ultrasound and a week later (38 days) on transabdominal ultrasound.

For pregnant women who are screened and rubella antibody is not detected, rubella vaccination after pregnancy should be advised. Vaccination during pregnancy is contraindicated because of a theoretical risk that the vaccine itself could be teratogenic, as it is a live vaccine. No cases of congenital rubella syndrome resulting from vaccination during pregnancy have been reported. However, women who are vaccinated postpartum should be advised to use contraception for three months.

Bicarbonate is the main buffer in blood.

This question assesses critical clinical knowledge, as this information must be presented to a patient prior to an amniocentesis to ensure that she has given her informed permission for the treatment.
Amniocentesis is most typically used for genetic counselling in the second trimester of pregnancy. Another option is to do a chorion-villus biopsy (CVB) between 10 and 11 weeks of pregnancy.
The chances of miscarriage after both operations are roughly 1 in 200 for amniocentesis and 1 in 100 for CVB, according to most experts.
The significance of this question is that professionals must be able to weigh the procedure’s danger against the risk of the sickness they are trying to identify.

The five year survival of stage 1 ovarian cancer is 70-90%

The pudendal nerve arises from the S2-S4 nerve roots and it lies medial to the internal pudendal artery while exiting the pelvis via the greater sciatic foramen. It curves around the sacrospinous ligament and re-enters the pelvis via the lesser sciatic foramen and from there it runs medial to the ischial tuberosity over the obturator internus in the pudendal canal to the deep perineal pouch.

The patient is suffering from Bartholin cyst abscess.
Insertion of an inflatable balloon is a non-surgical procedure that can be performed as an outpatient using a local anaesthetic (LA) injection to numb the area. It involves making a passage from the cyst or abscess through which the pus can drain over 4 weeks. After the LA injection, a small skin cut is made into the cyst or abscess, which allows drainage. A fluid/ pus swab sample may be taken to check for an infection at this stage. A cotton bud is used to break the pockets of abscess/ cyst fluid. A flexible tube (called a Word catheter) with a small, specially designed balloon at its tip is then inserted into the cyst or abscess to create a passage. The balloon is inflated with 3–4mls of sterile fluid to keep the catheter in place. Rarely, a stitch may be used to partly close the cut and hold the balloon in position. It is then left in place for up to 4 weeks; new skin to forms around the passage and the wound heals.

Marsupialization can be done for drainage but is inferior or word catheter because of the technical challenges and complications. Hot compressions and analgesics alone do not suffice in the presence of an abscess. Antibiotics are given after drainage but are not effective alone when there is a large collection of pus.

The Ovaries lymph drains primarily to the lateral para-aortic lymph nodes

Breech presentation refers to the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first.

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the foetus to turn into the vertex presentation in the third trimester include:
– Mullerian anomalies
– Placentation
– Uterine leiomyoma
– Prematurity
– Aneuploidies and fetal neuromuscular disorders
– Congenital anomalies
– Polyhydramnios and oligohydramnios
– Laxity of the maternal abdominal wall.

Heparin is a large-sized molecule and does not cross the placenta; it can provide anticoagulation in the mother, however, has no effect on the baby. Heparin is the preferred anticoagulant therapy during pregnancy.
Moreover, the anticoagulant effect of heparin can be rapidly reversed by protamine sulphate.
Warfarin, a coumarin derivative, takes much longer to be reversed compared to heparin. This can be given to the mother between 13 and 36 weeks of pregnancy, however, should be avoided in the first trimester due to its teratogenic effects.
The anticoagulant effect of coumarin derivatives on the baby also takes longer to be reversed.

Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate to allow the foetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large foetus, an unfavourable orientation of the foetus, or a combination of these factors. Diagnosis of CPD may be made when there is failure to progress, but not all cases of prolonged labour are the result of CPD. Use of ultrasound to measure the size of the foetus in the womb is controversial, as these methods are often inaccurate and may lead to unnecessary caesarean section; a trial of labour is often recommended even if size of the foetus is estimated to be large.

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. There are various risk factors for gestational diabetes including increasing age, ethnicity, previous still births etc.

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.

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 clinical picture, unusually high LH-to-FSH ratio (which should ordinarily be around 1:1), and higher androgens but normal DHAS all point to polycystic ovarian syndrome (PCOS). DHAS is an indicator of adrenal androgen production; when normal, it rules out adrenal hyperandrogenism. Several drugs have been used to treat PCOS-related hirsutism. Contraceptives were the most often used medications for many years; they can decrease hair growth in up to two-thirds of individuals. They work by decreasing ovarian steroid production and increasing hepatic-binding globulin production, which binds circulating hormones and lowers metabolically active (unbound) androgen concentrations. Clinical improvement, on the other hand, can take up to 6 months to show.
Medroxyprogesterone acetate, spironolactone, cimetidine, and GnRH agonists, all of which decrease ovarian steroid synthesis, have also shown potential. GnRH analogues, on the other hand, are costly and have been linked to severe bone demineralization in some patients after only 6 months of treatment. Given the efficacy of pharmacologic medications and the ovarian adhesions that were usually linked with this surgery, surgical wedge resection is no longer regarded as an appropriate therapy for PCOS.

This patient should be given promethazine and codeine as she presents with severe migraine.

Usage of metoclopramide is safe during pregnancy and for increasing effectiveness it can be added to paracetamol. However, because of its risk for causing extrapyramidal effects it should be used only as a second-line therapy and Promethazine should be considered as the first line choice of remedy. So the answer is Codeine and promethazine.

Opioid pain relievers such as codeine are not been reported of having any associated with increased birth defects or miscarriage, but its long-term use can lead to dependency in mother and withdrawal signs in the baby.

Paracetamol alone or combined with codeine is not found to be useful in controlling vomiting.

It is advised to completely avoid dihydroergotamine and the triptans throughout pregnancy.

The Pudendal provides cutaneous innervation to the posterior external genitalia via one of its terminal branches called the perineal nerve (this further branches into the posterior labial nerves or posterior scrotal nerve in men). The ilioinguinal nerve provides anterior sensation via the anterior labial nerves (anterior scrotal nerve in men). The genital branch of the genitofemoral nerve contributes some fibres to the skin of the mons pubis and labia majora in females. The posterior cutaneous nerve of thigh sometimes overlaps sensory areas.

In this case, the fundus height appears to be smaller than the suggested dates of gestation. However, this is uncertain as the exact gestation dates are not known. Head-sparing intrauterine growth restriction needs to be excluded or managed appropriately if detected.

The best initial management step would be to perform an ultrasound examination (correct answer). This would enable complete assessment of the foetus and all the measurable parameters can be determined. This would aid in identifying any discrepancy in size of the abdomen, limbs and head, and the liquor volume (amniotic fluid index) could be evaluated.

If asymmetrical growth restriction was detected via ultrasound examination, further evaluations such as cardiotocography (CTG) and umbilical arterial wave form analysis by Doppler could be initiated.

Additionally, foetal movement counting could then be commenced and evaluation of foetal lung maturity by amniocentesis could be considered.

If the ultrasound was normal (no evidence of asymmetrical growth restriction, normal amniotic fluid), repeat ultrasound should be performed after two weeks to evaluate the foetal growth.

If normal growth is observed on the repeat ultrasound, the estimated due date can be calculated (assuming normal foetal growth around the 50th percentile for the population).

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.

In the given case, the patient should be treated with Augmentin.
Asymptomatic bacteriuria occurs in about 2 % to 10 % of all pregnancies and if left untreated, about 30% of this will develop acute cystitis and the other 50% will develop acute pyelonephritis.

Escherichia coli is the most common pathogen associated with asymptomatic bacteriuria, which consists more than 80% of the isolate and Staphylococcus Saprophyticus accounts for about 5-10% of isolates associated with uncomplicated UTI. Escherichia coli is a very common normal flora found in the gastrointestinal tract and Staphylococcus Saprophyticus is a commonly found normal flora in genital tract and perineum.

Asymptomatic bacteriuria has found to be associated with low birth weight and preterm birth, and it is found that a short term antibiotic treatment will help in improving the fetal outcomes in cases of asymptomatic bacteriuria or uncomplicated UTI. Hence, all cases of asymptomatic bacteriuria and uncomplicated UTI during pregnancy are recommended to be treated with a five day course of oral antibiotics as this is normally sufficient in pregnant women.

Drug of choice in asymptomatic bacteriuria (directed therapy based on sensitivities) in case of E. coli are either:
– Cephalexin 500 mg oral twice a day for 5 days or
– Nitrofurantoin 100 mg orally twice daily for 5 days or
– Trimethoprim 300 mg oral doses daily for 5 days (avoided during first trimester and in those pregnant women with established folate deficiency, low dietary folate intake, or for women taking other folate antagonists).
– Amoxicillin + clavulanate 500 + 125 mg oral, twice daily for 5 days if < 20 weeks of gestation.
Note: In view of childhood outcomes – (ORACLE II trial and 7 year follow-up), which showed an associated increase in necrotising enterocolitis, functional impairment (low), and cerebral palsy, it is recommended that amoxicillin / clavulanate is only used if no alternative treatment is available(if >20 weeks of gestation).

Asymptomatic bacteriuria (directed therapy based on sensitivities ) in case of Staphylococcus saprophyticus infection is as follows:
Cephalexin 500 mg oral doses twice a day for 5 days or Amoxicillin 500mg TDS for 5 days.

Asymptomatic bacteriuria (directed therapy based on sensitivities) in case of infection with Pseudomonas suggest Norfloxacin 400 mg oral twice daily for 5 days, then repeat MSSU 48 hours after the treatment is completed.

In case of Group B streptococcus as a single organism, Penicillin V 500 mg oral twice daily for 5 days. If the patient is hypersensitive to penicillin give Cephalexin 500 mg orally twice a day for 5 days were immediate hypersensitivity is excluded. If immediate hypersensitivity to penicillin is noticed, then Clindamycin 450 mg three times daily for 5 days is advised.

Amoxicillin is found more effective in treating UTIs caused by organisms which are resistant to the drug in vitro because of its high concentrations attainable in urine. However, a study shows that amoxicillin-resistant organisms do not respond to amoxicillin alone but Augmentin [amoxicillin clavulanate] is found to cure urinary tract infection irrespective of the amoxicillin susceptibility of the organism in vitro. Of the patients infected with amoxicillin-resistant organisms, 80% were cured by augmentin and only 10% with infection by amoxicillin-resistant organisms were cured by amoxicillin.

Now a days Amoxicillin is not preferred as the common treatment option for UTI due to increasing incidences of Escherichia coli resistance, which accounts majority of uncomplicated urinary tract infections. Clavulanic acid which is a beta-lactamase inhibitor works synergistically with amoxicillin to extend spectrum antibiotic susceptibility. This makes UTIs less likely to be resistant to the treatment with amoxicillin clavulanate compared to amoxicillin alone.
Ciprofloxacin and Gentamicin which are the other antibiotic choice considered otherwise also should be avoided in pregnancy as they comes under FDA pregnancy Category C.

Post coital literally means “after intercourse” which is when this fertility test is conducted. The patient has intercourse at home usually between cycle days 12 and 15 (or a day around the LH surge as measured by urinary ovulation predictor kits). Afterwards, the female comes to the office and a sample of the cervical mucus is taken for microscopic examination.

The post coital fertility test (PCT) allows for evaluation of sperm in the cervical mucus and to determine the consistency of the mucus. Sperm must swim through the cervical mucus from the vagina, through the cervix, and into the uterus. Normal sperm will be active and swim in approximate straight lines through the mucus. If the mucus is too thick, sperm impedance can be observed.

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.

Luteal phase occurs after the ovulation. Luteal defect means that the luteal phase is shorter than 10 days and women will find it difficult to sustain the pregnancy. There is decreased progesterone, LH and FSH production in this case.

99.7% of cervical cancers among women are related to Human Papilloma virus infection (HPV).

Corpus albicans is the regressed form of the corpus leuteum. It is formed when the corpus leuteum is engulfed by macrophages and a scar or fibrous tissue is formed, called the corpus albicans.

The occurrence of migraine in women is influenced by hormonal changes throughout the lifecycle. A beneficial effect of pregnancy on migraine, mainly during the last 2 trimesters, has been observed in 55 to 90% of women who are pregnant, irrespective of the type of migraine.

For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) preferably as a suppository is considered the first choice drug treatment. The risks associated with use of aspirin (acetylsalicylic acid) and ibuprofen are considered to be small when the agents are taken episodically and if they are avoided during the last trimester of pregnancy.

Paracetamol 500 mg alone or in combination with metoclopramide 10 mg are recommended as first choice symptomatic treatment of a moderate-to-severe primary headache during pregnancy.

This patient has acidosis as the pH is low <7.35 The pO2 is irrelevant. The pCO2 is raised i.e. the respiratory system is causing acidosis. The patient is acidotic so this is a respiratory acidosis The Base Excess is normal. You would typically expect the base excess to rise but metabolic compensation is slower than respiratory compensation so this picture may be seen acutely.

Dizygotic means two (di) fertilized eggs (zygotes). Dizygotic twins occur when two eggs are fertilized by two separate sperm. Dizygotic twins are also known as fraternal or non-identical twins. They are the most common type of twins.

Unlike monozygotic twins (also known as identical twins), dizygotic twins do not share the same genes. Monozygotic twins share 100 percent of each other genes. Dizygotic twins share only 50 percent. This is the same genetic similarity found between siblings conceived and born at different times.

Reported cure rates for an episode of acute BV vary but have been estimated to be between 70% and 80%. Unfortunately, more than 50% of BV cases will recur at least once within the following 12 months. Because the aetiology of BV is still not entirely understood, identifying the cause of recurrent cases is challenging. Reinfection may play a role in explaining recurrent BV, but
treatment failure is a more likely contributor. There are several theories that try to explain recurrence and persistent symptoms. The existence of a biofilm in the vagina is one such theory and is the subject of ongoing research. Biofilms occur when microorganisms adhere to surfaces. G vaginalis, one of the primary organisms

BV is not a sexually transmitted infection. The antibiotic of choice to treat BV is Metronidazole. Reassurance is not acceptable as a means of treatment.

Because of the high possibility of spontaneous resolution and the fact that if the cystic mass was verified ultrasonically, a conservative policy would almost probably be proposed for at least another six weeks, an ultrasound examination is not necessary at this time. If the cyst is still present at the six-week check, an ultrasound examination is required, as it is likely that the cyst is a benign tumour or possibly endometriosis. It’s quite improbable that it’s cancer.
Additional tests, such as computed tomography (CT) examination and potentially surgical removal or drainage, may be required in the future, although not at this time.
This cyst in a young lady is almost probably of physiological origin, especially given its size. The woman should be informed, but a follow-up examination is required. The most suitable next action is to return in six weeks, as the cyst is most likely physiologic and will most likely dissipate naturally by then. The following appointment should not take place during the same menstrual cycle.

For this pregnant patient who recently travelled overseas most likely has a deep venous thrombosis (DVT). It would also be expected that the patient would have oedema in the symptomatic leg and account for the swelling described.

Though they could cause unilateral leg pain, neither symphyseal separation nor sciatica due to a prolapsed intervertebral disc usually occur as early as 18 weeks of gestation. This patient’s symptoms also do not suggest either diagnosis.

Pain due to trauma would usually be maximal at the site where the trauma took place, which would be in the knee for this patient. Traumatic pain and house cleaning also would not cause the pain described or result in ankle swelling.

The uterine artery arises from the internal iliac artery, in particular the anterior division of the internal iliac artery. Some older texts refer to the internal iliac as the hypogastric artery. The vaginal artery typically arises as its own branch of the internal iliac artery. The ovarian arteries are branches of the aorta

Remember patients with PCOS have elevated LH. COCPs suppress synthesis and secretion of FSH and the mid-cycle surge of LH, thus inhibiting the development of ovarian follicles and ovulation COCPs reduce hyperandrogenism as reduced LH secretion results in decreased ovarian synthesis of androgens. Furthermore they stimulate the liver to produce Sex Hormone Binding Globulin which leads to decreased circulating free androgens. Other mechanisms include reduction in adrenal androgen secretion and inhibition of peripheral conversion of testosterone to dihydrotestosterone and binding of dihydrotestosterone to androgen receptors

Tocolysis is an obstetrical procedure to prolong gestation in patients, some of which are experiencing preterm labour. This is achieved through various medications that work to inhibit contractions of uterine smooth muscle.

There is no definitive first-line tocolytic agent by the American College of Obstetrics and Gynecology (ACOG) but nifedipine is most commonly used. However, in severe aortic stenosis, nifedipine can cause ventricular collapse and dysfunction.

The therapeutic target in the treatment of preterm labour is currently the pharmacological inhibition of uterine contractions with the use of various tocolytic agents. Tocolytic agents are used to maintain pregnancy for 24–48 hours to allow corticosteroids administration to act and to permit the transfer of the mother to a centre with a neonatal intensive care unit.

Oxytocin inhibitors work by competitively acting at the oxytocin receptor site. Oxytocin acts to increase the intracellular levels of inositol triphosphate. The medications currently in this class are atosiban and retosiban. Maternal nor fetal side effects have not been described for this tocolytic.

This patient presents with secondary amenorrhea, most likely caused by Asherman’s syndrome- Secondary amenorrhea is defined as absence of menstruation for – 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea- Asherman’s syndrome as the cause of her amenorrhea is suggested by its beginning shortly after undergoing elective abortion. It is an outflow tract obstruction caused by intrauterine synechiae resulting from the procedure.

The best diagnostic test to confirm this diagnosis is hysteroscopy. It can allow visualization of the uterine cavity, the nature and extent of intrauterine synechiae.

→ Progesterone withdrawal test is one of the diagnostic studies done in the early work-up of secondary amenorrhoea- It is usually followed by the estrogen-progesterone challenge test and other tests. Progesterone withdrawal test alone would not confirm Asherman’s syndrome.
→ Pelvic ultrasound is more useful in primary amenorrhea work-up when the presence or absence of the uterus is to be confirmed- It is not very useful in the evaluation of intrauterine adhesions.
→ Brain MRI is useful in confirming the presence of pituitary tumours in patients, who are found to have high levels of prolactin. This patient’s most likely cause of secondary amenorrhea is Asherman’s syndrome.
→ TSH and prolactin levels should be the next step in the work-up of secondary amenorrhea after pregnancy has been ruled out; however, these studies cannot confirm Asherman’s syndrome.

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.

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.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

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.

Ergot alkaloids e.g. Ergometrine, produce marked and prolonged alpha receptor mediated vasoconstriction. Its overdose can cause ischemia and gangrene of the limbs and bowel. It also causes coronary artery spasm and has been used by cardiologist as a provocation test.

Lichen sclerosis (LS) is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by symptoms of pruritus and pain.

Topical corticosteroids are the mainstay of therapy. Intralesional corticosteroid therapy is an additional option that is useful for the treatment of thick hypertrophic plaques that topical corticosteroids may not penetrate adequately.

Antibiotics or antifungals have no role in the treatment of LS since it’s not an infection.
Since histological diagnosis has already been made, there is no need to refer to dermatologist.
Surgical intervention is indicated for treatment of complications like adhesion and scarring.

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

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

Institute of Medicine Weight Gain Recommendations for Pregnancy: Recommends a gestational weight gain of 16.8–24.5 kg (37–54 lb) for women of normal weight, 14.1–22.7 kg (31–50 lb) for overweight women, and 11.3–19.1 kg (25–42 lb) for obese women.

This patients bloods and symptoms suggest she has hepatic impairment. Acute fatty liver of pregnancy typically presents after the 30th week and she has risk factors for acute fatty liver of pregnancy: Multiple pregnancy Primigravida

Trichomoniasis is considered a sexually transmitted infection found both in men and women 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. 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 for a HIV positive woman who is pregnant is 500mg of metronidazole twice daily for 7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated, and screening for other STIs should be carried out.

Circulation in the foetus: 1. Deoxygenated fetal blood is conducted to the placenta via the two umbilical arteries. The umbilical arteries arise from the internal iliac arteries.
2. Gas exchange occurs in placenta.
3. Oxygenated blood from the placenta passes through the single umbilical vein and enters the inferior vena cava (IVC).
4. About 50% of the blood in the IVC passes through the liver and the rest bypasses the liver via the ductus venosus. The IVC also drains blood returning from the lower trunk and extremities.
5. On reaching the heart, blood is effectively divided into two streams by the edge of the interatrial septum (crista dividens) (1) a larger stream is shunted to the left atrium through the foramen ovale (lying between IVC and left atrium) (2) the other stream passes into right atrium where it is joined by blood from SVC which is blood returning from the myocardium and upper parts of body. This stream therefore has a lower partial pressure of oxygen.
6. Because of the large pulmonary vascular resistance and the presence of the ductus arteriosus most of the right ventricular output passes into the aorta at a point distal to the origin of the arteries to the head and upper extremities. The diameter of the ductus arteriosus is similar to the descending aorta. The patency of the ductus arteriosus is maintained by the low oxygen tension and the vasodilating effects of prostaglandin E2;
7. Blood flowing through the foramen ovale and into left atrium passes into the left ventricle where it is ejected into the ascending aorta. This relatively oxygen rich blood passes predominantly to the head and upper extremities.

The condition should be an X-linked recessive condition, as it affects only male offspring. Duchene muscular dystrophy is an X-linked recessive condition. Cystic fibrosis is an autosomal recessive disorder. Spina bifida is a multifactorial condition. Down syndrome is caused by trisomy of chromosome 21. Spinal muscular atrophies are inherited in an autosomal-recessive pattern.

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.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.

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.

Stress incontinence is characterized by the involuntary loss of urine with increases in intra-abdominal pressure. It is the most common type of incontinence in younger women, but also occurs in older women. Key risk factors include childbirth, medications that relax the urethral sphincter, obesity, lung disease (from chronic cough), and prior pelvic surgeries. Numerous treatments are available, although few studies compare one treatment with another.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Routine urodynamic tests are not recommended for urinary incontinence. Surgery is reserved for refractory incontinence.

HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.

Genetically, patients suffering from androgen insensitivity syndrome are 46XY. They are males but insensitive to male hormones i.e. androgens.

A ruptured ectopic pregnancy is the most probable diagnosis. As she is in shock (tachycardia and hypotension) immediate laparotomy is needed.

With a history of MI, oestrogen and COCP should be avoided. Evening primrose is also not suitable for post-menopausal symptoms. Raloxifene is a SERM – these make hot flushes worse. Clonidine will help improve the hot flushes and the vasomotor symptoms.

When it comes to questions on venous drainage the ovarian vein is likely to be a common question given its varied drainage depending on laterality. The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

Clomiphene and/or Metformin are 1st line agents. Weight loss in the setting of subfertility is advised if BMI >30 kg/m2

Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.

The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic
henodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.

Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta- Mild elevation of gamma glutamyl transferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.

It utilizes the IgG class of the antibody.

Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma’s) sometimes called myoma’s.

This is typical appearance of molar pregnancy. This used to be referred to as ‘snowstorm sign’ as with older poorer resolution ultrasound the anechoic species looked like a snowstorm.

Since the car crash happened two weeks prior, breast trauma is suggested and thus fat necrosis is the most probable diagnosis. Phyllodes tumours are typically a firm, palpable mass. These tumours are very fast-growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50, prior to menopause.