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.

These are the most common ovarian tumours in young women. The most common form is the mature dermoid cyst (cystic teratoma). It can consist of a combination of all the type of tissues (mesenchymal, stromal and epithelial). Any mature tissue type can be present such as muscle, cartilage, bone, teeth and often hair. Treatment is cystectomy.

According to the Royal College of Obstetrics and Gynaecology guidelines for abortion care it advises dual antibiotic regimes for antibiotic prophylaxis.
Metronidazole 1g per rectum or 800 mg orally can be given before or at the time of the abortion in women who have tested negative for Chlamydia trachomatis infection.

Alternatively, Doxycycline (100mg oral, twice daily for 7 days) or Azithromycin 1g stat doses should be given in addition to metronidazole to be effective against Chlamydia trachomatis anaerobes.

The incubation period of rubella is 12-23 days.

Fetal production of immunoglobulin begins early on, at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity, is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth.

Consuming alcohol and risk of cervical cancer are not associated. Not even drinking often and in large amounts are risk factors for developing cervical cancer.

So drinking alcohol and risk of cervical cancer aren’t associated. Based on their analyses of the scientific research evidence, that is the conclusion of, among many others, the:
American Cancer Society.
Centres for Disease Control and Prevention (CDC).
National Cancer Institute.
UK’s National Health Service.
Canadian Cancer Society.
Cancer Council Australia.
World Health Organization (WHO).

All other options can increase the risk of acquiring cervical cancer.

It is stage 2B. Stage I: is strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion.
2010 FIGO classification of cervical carcinoma:
Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.

Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
Stage IB1: Clinical lesions no greater than 4 cm in size.
Stage IB2: Clinical lesions greater than 4 cm in size.

Stage II: carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall.

Stage III: carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.

Stage IV: carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.
Stage IVA: Spread of the tumour into adjacent pelvic organs.
Stage IVB: Spread to distant organs.

Dizygotic twin pregnancies are known to increase with age of the mother. Naturally conceived twins are thought to occur in a 0.3% rate in women under 25 years, 1.4% between 25 and 34, 3% between 34 and 39, and 4.1% in women in their 40s or over. We also know that at least 50% of all twin pregnancies are conceived through ART and that this proportion is probably higher for women in their 40s.

Progestogen-only methods are contraindicated in suspected pregnancy, breast cancer and undiagnosed vaginal bleeding. Giving DMPA to a woman with a severe bleeding disorder may result in a large haematoma at the injection site.

Women who want to become pregnant within 18 months or who are afraid of injections should be discouraged from using DMPA. Progestogen-only methods are unsuitable for women unwilling to accept menstrual changes.

Relative contraindications are active viral hepatitis and severe chronic liver disease. For all progestogen-only methods, with the possible exception of DMPA, drug interactions are likely with many anticonvulsants, rifampicin, spironolactone and griseofulvin. This may result in lowered efficacy.

Migraine, malabsorption syndrome, smoking and history of liver disease have not been identified as contraindications to mini pills.

Polycystic kidney disease (PKD) can either be autosomal dominant or recessive. The autosomal dominant variant is more common in adult PKD however, the recessive pattern is more common in infantile PKD.

As this is a simple cyst less than 50mm in diameter the patient does not require further investigation or routine follow up

A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour

If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.

Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.

No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.

Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin.

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.

The ischial spine is the anatomical landmark for assessing the station of the fetal head and also placing pudendal nerve blocks. (the pudendal nerve runs posterior to the ischial spine). The ischial spine can be palpated approximately 8cm into the vagina, at 4 and 8 o’clock.

Detrusor contraction is via Parasympathetic innervation of pelvic splanchnic nerves (S2-4). This also causes relaxation of the internal urethral sphincter Note contraction and relaxation of the external urethral sphincter is under somatic control.

Combined oral contraceptive pills (COCPs) can be started immediately following abortion or miscarriage. Note following childbirth COCPs should not be restarted for 3 weeks (assuming the patient is not breastfeeding).

During the first 12 weeks of pregnancy, cardiac output increases by about 30-50%. To maintain this increase, systemic vascular resistance decreases by 20-30%, while stroke volume and the heart rate increase by 25-30% and 15 beats per minute respectively.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

Women with polycystic ovary syndrome (PCOS) have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed oestrogen that results from anovulation.

Additionally, secretory endometrium of some women with PCOS undergoing ovulation induction or receiving exogenous progestin exhibits progesterone resistance accompanied by dysregulation of gene expression controlling steroid action and cell proliferation.

Other risk factors include nulliparity, early menarche and late menopause, obesity and family history of endometrial cancer. Which rules out all the other options.

Chlamydia trachomatis (D-K subtypes) is the most common cause in this age group and fits the descriptors given.

This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

Caesarean section is rarely needed to be done when the foetus is already dead.

Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

It is usual to experience heavy, continuous bleeding around the time of menarche.
Haemoglobin and ferritin levels are used to determine the severity of bleeding and its impact on the haemoglobin level.
These analyses do not pinpoint the source of the problem, but they do pinpoint its consequences.
A haematologic reason, such as thrombocytopenia, acute leukaemia, or a coagulation/bleeding issue, affects about one-third of girls with pubertal menorrhagia (e.g. von Willebrand disease).
A complete blood examination and a bleeding
lotting profile are required to rule out these illnesses.
The results of a haemoglobin estimation or a ferritin level evaluation are insufficient, and the results of dilatation and curettage (D&C) or magnetic resonance imaging (MRI) will rarely reveal the reason for the bleeding.

E.coli is the most common cause of UTI. Other organisms include pseudomonas, proteus and klebsiella.

NICE guidelines: UTI in pregnancy (updated in July 2015)

Send urine for culture and sensitivity from all women in whom UTI is suspected before starting empirical antibiotics and 7 days after antibiotic treatment is completed.
Prescribe an antibiotic to all women with suspected UTI (awaiting culture result is not advised)
Although local antibiotic resistance needs to be taken into account the following is advised in terms of antibiotic selection:
1. Nitrofurantoin 50 mg QDS (or 100 mg MR BD) for 7 days.
2. Trimethoprim 200 mg twice daily, for 7 days
Give folic acid 5 mg OD if it is the 1st trimester
Do not give trimethoprim if the woman is folate deficient, taking a folate antagonist, or has been treated with trimethoprim in the past year.
3. Cefalexin 500 mg BD (or 250 mg 6qds) for 7 days

Detrusor overactivity can be treated with anti-cholinergic agents such as oxybutynin or tolterodine, solifenacin, fesoterodine and darifenacin. They are used as first line agents. Imipramine is used for enuresis and desmopressin is used for nocturia.
NICE pathway

Prior to initiating anticholinergics:
Bladder training
Consider treating vaginal atrophy and nocturia with topical oestrogen and desmopressin respectively before commencing treatments below.
Consider catheterisation if chronic retention
1st line treatments:
1. Oxybutynin (immediate release) – Do not offer to frail elderly patients
2. Tolterodine (immediate release)
3. Darifenacin (once daily preparation)
DO NOT offer any of the 3 drugs below:
1. Flavoxate
2. Propantheline
3. Imipramine
2nd line treatment
Consider transdermal anticholinergic (antimuscarinic)
Mirabegron
Adjuvant Treatments
Desmopressin can be considered for those with nocturia
Duloxetine may be considered for those who don’t want/unsuitable for surgical treatment
Intravaginal oestrogen can be offered to postmenopausal women with OAB

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

Glucagon release is inhibited by increased blood glucose, ketones, free fatty
acids, insulin, raised urea levels and somatostatin. Glucagon is produced by alpha cells of the pancreas and increases the plasma glucose level by stimulating glycogenolysis and gluconeogenesis.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

Pelvic Outlet Boundaries Anteriorly: Pubic arch Laterally: Ischial tuberosities Posterolaterally: Inferior margin of the sacrotuberous ligament Posteriorly: Tip of the coccyx Note: The pelvis outlet is also called the inferior aperture. The pelvic brim is the superior aperture

Nausea, fatigue, breast tenderness, and increased frequency of urination are the most common symptoms of pregnancy, but their presence is not considered definitive as they are nonspecific symptoms which are not consistently found in early pregnancy, also these symptoms can occur even prior to menstruation.

In pregnancy a physical examination will reveal an enlarged uterus which is more boggy and soft, but these findings are not apparent until after 6th week of gestation. In addition, other conditions like adenomyosis, fibroids, or previous pregnancies can also result in an enlarged uterus which is palpable on physical examination.

An abdominal ultrasound will not demonstrate a gestational sac until a gestational age of 5 to 6 weeks, nor will it detect an ectopic pregnancy soon after a missed menstrual period, therefore it is not indicated in this patient.

A Doppler instrument will detect fetal cardiac action usually after 10 weeks of gestation.

A sensitive serum quantitative pregnancy test can detect placental HCG levels by 8 to 9 days post-ovulation and is considered as the most appropriate next step in evaluation of this patient.

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

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

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

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

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

There are several risk factors for gestational diabetes:
Increasing age
– Certain ethnic groups (Asian, African Americans, Hispanic/Latino Americans and Pima Indians)
– High BMI before pregnancy (three-fold risk for obese women compared to non-obese women)
– Smoking doubles the risk of GDM
– Change in weight between pregnancies – an inter-pregnancy gain of more than three units (of BMI) doubles the risk of GDM
– Short interval between pregnancies
– Previous unexplained stillbirth
– Previous macrosomia
– Family history of type 2 diabetes or GDM – more relevant in nulliparous than parous women

High polyunsaturated fat intake has been shown in some studies to be protective against gestational diabetes. Physical activity is also thought to be effective.

An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

There is 70% chance that a women who has had a C-section can deliver via spontaneous vaginal delivery.

Wound healing typically undergoes different stages that include haemostasis, inflammation, proliferation and remodelling. The phases are often shortened when healing occurs by primary intention such as in a surgical wound. Remodelling, which is the major strengthening phase, takes about 3 weeks, while it takes a total of 12 weeks to reach maximum tensile strength.

The diagnosis of functional ovarian cyst is made when the cyst measures more than 3 cm and rarely grows more than 10 cm. It appears as a simple anechoic unilocular cyst on USS. It is usually asymptomatic. If it is symptomatic then laparoscopic cystectomy should be performed.

On reflex liquid-based cytology, this patient had a cervical screening test that revealed HPV non-16 and 18 kinds, as well as a low-grade squamous intraepithelial lesion. In a year, she should be provided a cervical screening test. If HPV non-16/18 kinds are discovered in 12 months, she will need a colposcopy.

DHEA is formed in the mother’s adrenal gland as well as the fetal adrenal glands. These weak androgens are transported by the blood to the placenta and are converted into oestradiol, estrone and estriol in the trophoblast.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

Maternal exposure to dietary factors during pregnancy can influence embryonic development and may modulate the phenotype of offspring through epigenetic programming. Folate is critical for nucleotide synthesis, and preconceptional intake of dietary folic acid (FA) is credited with reduced incidences of neural tube defects in infants.

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.

Clomiphene citrate is widely used in the induction of ovulation, especially in the treatment of anovulatory infertility and in conditions such as PCOS. The drug functions as a selective oestrogen receptor modulator, which acts in the hypothalamus to indicate low serum oestrogen levels. Reduced levels of negative feedback stimulate the secretion of GnRH from the hypothalamus, which in turn stimulate the production of gonadotropins (FSH and LH) from the anterior pituitary. These work to increase ovarian follicular activity.

The internal anal sphincter is innervated by the splanchnic nerves. Sympathetic nerve supply from the inferior hypogastric plexus (for contraction) and parasympathetic supply from nervi erigentes (for relaxation).

Diastolic murmurs occur in conditions such as mitral stenosis, tricuspid stenosis and even in carditis. They are always pathological during pregnancy. Systolic murmurs and left axis deviation may be normal during pregnancy due to an increase in the blood volume and load on the heart.

Mitosis is the process during which cell division occurs. It is divided into 4 stages:
– The first stage is the prophase during which the chromosomes condense, mitotic spindles form and the chromosomes pair which each other.
– The second stage is the metaphase during which the chromatids align at the equatorial plane.
– The third stage is the anaphase during which the chromatids are separated into 2 daughter chromosomes.
– The fourth phase is the telophase during which the chromatids decondense and a new nuclear envelop forms around the each of the daughter chromosomes. Cytokinesis is the process during which the cell cytoplasm divides.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.

Incontinence in women is typically related to dysfunction of the bladder or pelvic floor muscles, with such dysfunction often arising during pregnancy or childbirth, or at the time of menopause.

A pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women

The amniotic fluid volume increases up to week 35 of gestation and then decreases from then to term.

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.

Involution of the uterus takes 4-6 weeks