The pelvic floor or diaphragm is composed of Coccygeus and Levator Ani. Levitator Ani is composed of 3 muscles: puborectalis, pubococcygeus and iliococcygeal. Although Piriformis assists in closing the posterior pelvic outlet it is not considered a component of the pelvic floor

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

Factor V Leiden is the most common congenital thrombophilia. Named after the Dutch city Leiden where it was first discovered. Protein C and S deficiencies are type 1 (Not type 2) thrombophilias Antiphospholipid syndrome is an acquired (NOT congenital) thrombophilia

This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes haemoglobin, haematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid- A peripheral smear and coagulation profiles also may be obtained- Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

→ Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
→ It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
→ Delivery is the definitive treatment for preeclampsia- The timing of delivery is determined by the gestational age of the foetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over caesarean delivery, if possible, in patients with preeclampsia.

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

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

Rubella infection during pregnancy may lead to miscarriage, intrauterine fetal demise, premature labour, intrauterine growth retardation, and congenital rubella syndrome. The risk of developing complications is highest if the infection is contracted within the first 12 weeks of gestation.

In those cases in which a pregnant woman has been exposed to a suspected rubella case, a specimen of blood should be tested as soon as possible for the measurement of rubella-specific IgG antibodies. If it is positive, then the woman was likely to be immune and could be reassured. If it is negative, a determination rubella-specific IgG and rubella-specific IgM antibodies should be obtained in 3 weeks to exclude an asymptomatic primary rubella infection.

Serum progesterone has been proposed as a useful test to distinguish a viable pregnancy from a miscarriage or ectopic pregnancy. Low progesterone values are associated with miscarriages and ectopic pregnancies, both considered non-viable pregnancies, and high progesterone concentrations with viable pregnancies. A single progesterone measurement for women in early pregnancy presenting with bleeding or pain and inconclusive ultrasound assessments can rule out a viable pregnancy. The probability of a non-viable pregnancy was raised from 62.9% to 96.8%.

Adolescents who fail to respond to first- or second-line treatment and have recurrent symptoms or have symptoms that worsen over time should be re-evaluated for other possible and serious causes of secondary dysmenorrhea such as endometriosis, uterine leiomyomas, polyps, or pelvic pathologies.

When pelvic pathology is suspected, abdominal and transvaginal ultrasonography should be used as first-line investigation. However, transvaginal ultrasound is more accurate and the preferred option if possible.

CT scan is not indicated in the assessment of dysmenorrhea.

D&C and laparoscopy can be considered as treatment options once a diagnosis has been established but can not be used as primary steps in diagnosis of dysmenorrhea.

Molding allows the skull bones of the fetal head some mobility during the normal delivery of foetus as the skull changes its shape to accommodate passage through the mothers pelvis. However this does not occur in breach delivery where the skull is in circular shape. Babies born breech typically have craniofacial and limb deformations resulting from their in utero position. These babies characteristically have a long, narrow head, (“dolichocephaly” or “type 1”), with a prominent occipital shelf, redundant skin over the neck, overlapping lambdoidal sutures, and an indentation below their ears (from shoulder compression).

Up to 20% of women have been found to have Group B streptococcus (GBS). GBS is considered a normal flora of the gastrointestinal tract. GBS infection is generally asymptomatic although some women might end up having a UTI. Infants born to mothers who are colonised with GBS during labour are at a higher risk of developing early-onset GBS infection. If a pregnant woman develops a UTI due to GBS, it is suggestive of significant GBS colonisation. IV penicillin would be the drug of choice and is to be administered to the mother during labour which would provide sufficient protection for the foetus and would be effective enough. If penicillin is unavailable, ampicillin is a reasonable alternative. If a patient has penicillin allergy, vancomycin can be used. If not for penicillin, roughly 50% of babies delivered vaginally to women who are GBS positive would be colonised with the organism and out of this percentage, 1-2% can go on to develop a severe infection such as septicaemia and meningitis which could often be fatal.

IM penicillin can be administered to the newborn immediately post-delivery would be an effective prophylaxis in most cases but one should not wait until signs of infection are present to give the injection. Many newborns would still have an immature immune system which could cause some to die. Hence, it is more suitable to treat all women who tested positive during labour and the newborn as well if any signs of infection do appear. The majority of babies don’t need antibiotic treatment if their mother has been treated.

As the mother is found to be rhesus negative while her baby being rhesus positive, the given case is clinically diagnosed as spontaneous abortion due to Rh incompatibility. The mother should be administered anti-D for prophylaxis for avoiding future complications.

Rhesus (Rh) negative women who deliver a Rh-positive baby or who comes in contact with Rh positive red blood cells are at high risk for developing anti-Rh antibodies. The Rh positive fetuses
eonates of such mothers are at high risk of developing hemolytic disease of the fetus and newborn, which can be lethal or associated with serious morbidity.
In such situations both spontaneous and threatened abortion after 12 weeks of gestation, are indications to use anti-D in such situations.

All the other options are incorrect.

Toxoplasma Gondii is an intracellular parasite which is excreted in cat faeces and then transferred to humans through secondary hosts. During pregnancy, it can be transmitted to the neonate. The risk of transplacental transmission from mother to foetus is greater in later pregnancy i.e. 26-40 weeks but during this time period it is less dangerous as compare to the transmission during 0-10 weeks of gestation. It may lead to abortion, microcephaly, hydrocephalus, cerebral calcifications, cerebral palsy and seizures.

The pudendal nerve is formed by sacral nerve roots S2, S3 and S4 almost immediately as they exit the spinal foramina. The pudendal nerve exits the pelvis via the greater sciatic foramen, travels behind the sacrospinous ligament before re-entering the pelvis via the lesser sciatic foramen. It is an important nerve to be aware of as it supplies sensation to the genitalia and can also be damaged/compressed at a number of places along its course. Image sourced from Wikipedia

MEDIAL umbilical ligament = remnant fetal umbilical arteries
MEDIAN umbilical ligament = remnant of urachus

Women with diabetes have increased risk for adverse maternal and neonatal outcomes and similar risks are present for either type 1 or type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies, and to minimize risk of congenital defects. Haemoglobin A1c goal at conception is <6.5% and during pregnancy is <6.0%.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.

Elevated fasting plasma glucose means gestational diabetes mellitus and is not considered to be in the spectrum of a normal pregnancy. In normal pregnancy however, maternal tissues become progressively insensitive to insulin. This is believed to be caused partly by hormones from the placenta and partly by other obesity and pregnancy related factors that are not fully understood. Gestational diabetes mellitus (GDM) occurs in about 5% of pregnancies but figures vary considerably depending upon the criteria used and demographic characteristics of the population.

The number of stillbirths and deaths in the first week of life per 1000 births.
According to WHO the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

The use of lamotrigine during pregnancy has not been associated with an increased risk of neural tube defects; however, the recommendation regarding higher doses of folic acid supplementation is often, but not always, broadened to include women taking any anticonvulsant, including lamotrigine.

All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

Varicella is a live vaccine. The recent RCOG green top guidelines suggest vaccine can be considered postpartum or pre pregnancy but NOT whilst pregnant. In the non-immune pregnant woman they should be advised to avoid contact with people with chickenpox or shingles and to contact a healthcare professional promptly if exposed. If they have a significant exposure VZIG should be offered as soon as possible.

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.

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

In pregnancy, progesterone is produced by the corpus luteum followed by the placenta- Exogenous progesterone will not lead to withdrawal bleeding. In ovarian failure as well as pituitary failure, no oestrogen stimulation of the endometrium exists, and progesterone cannot cause withdrawal bleeding. With Mullerian agenesis, there is no endometrium. Polycystic ovarian syndrome has an abundance of circulating oestrogen, so the endometrium will proliferate.

→ In pregnancy progesterone withdrawal will not occur since the corpus luteum is producing progesterone- The placenta will take over, starting at 7 weeks, and will be the sole producer of progesterone by 12 weeks.
→ In ovarian failure no oestrogen will be produced; no proliferation of the endometrium will occur.
→ Pituitary failure is an incorrect answer because without gonadotropin stimulation, there will not be enough oestrogen to stimulate the endometrial lining.
→ Mullerian agenesis is an incorrect answer – there is no uterus, thus no bleeding.

The third stage of labours starts from the delivery of the foetus to the delivery of the placenta and the membranes.

In stage III cervical cancer there is involvement of the pelvic wall and ureter which may result in abdominal pain and hydronephrosis.

2010 FIGO classification of cervical carcinoma

Stage
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, Greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis
4A – Invades mucosa bladder and rectum
4B – Distant Metastasis

Most types of HRT increase the risk of breast cancer. But the risk is higher for those using combined HRT, which uses both oestrogen and progestogen. Vaginal oestrogens are not linked to an increased risk of breast cancer, whereas tibolone is. Taking HRT for 1 year or less only slightly increases breast cancer risk. However, the longer you take HRT the greater the risks are, and the longer they last.

Evidence is insufficient to conclude that long-term oestrogen therapy or hormone therapy use improves cardiovascular outcomes.

HRT containing oestrogen alone increases risk of endometrial cancer. However, this is not the case when using combined HRT.

A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.

Fat necrosis is often a result of a trauma or surgery. In fat necrosis the enzyme lipase releases fatty acids from triglycerides. The fatty acids combine with calcium to form soaps. These soaps appear as white chalky deposits which are firm lumps with no associated discharge. The given case has a bruise which indicates prior trauma.