Indications for FBS:
1. Pathological CTG in labour (cervix dilated >3 cm)
2. Suspected acidosis in labour (cervix dilated >3 cm)
Contraindications to FBS:
– Maternal infection e.g. HIV, HSV and Hepatitis
– Known fetal coagulopathy
– Prematurity (< 34 weeks gestation)
– Acute fetal compromise

Patient in the given case has developed clinical features of mild preeclampsia presented as hypertension, ankle and facial oedema along with proteinuria.

As the fetal lungs are not yet matured, best management in this case would be observing the patient frequently, starting her on steroids and antihypertensive drugs like methyldopa, or labetalol. 31 to 34 weeks of gestation is the optimal gestational age for starting dexamethasone therapy which will help in controlling blood pressure, helps in the maturation of lungs and will also gives time to organise delivery when the lungs are matured.

Immediate C-section is not required at this stage of pregnancy, however a plan for cesarean section must be made to carry it out if the patient develops eclampsia during her stay in the hospital. Immediate vaginal delivery is also not indicated as the pregnancy is far from term. Induced labour will result in fetal demise soon after birth due to the fetal lung immaturity, but immediate delivery has to be considered once the fetal lung attains maturity.

Magnesium Sulphate is indicated only in women with severe pre-eclampsia and even in such cases primary importance is given to blood pressure controlling. Magnesium sulphate is not indicated on this case as the patient is in mild eclampsia.

Even though Paracetamol and deep vein thrombosis prophylaxis are indicated in this case, anticoagulants should be avoided considering the emergency need for surgery.

Vaginismus is an uncontrollable painful spasm of the pelvic muscles and vaginal exit that this patient has. It’s mainly caused by psychological factors. It’s important to distinguish it from frigidity, which indicates a lack of sexual desire, and dyspareunia, which is characterized as pelvic and/or back pain or other discomfort linked with sexual activity. Endometriosis, pelvic adhesions, and ovarian neoplasms are all common causes of dyspareunia. Vaginismus pain can be psychogenic, or it might be caused by pelvic diseases like adhesions, endometriosis, or leiomyomas. Organic vulvar or pelvic reasons (such as atrophy, Bartholin gland cyst, or abscess) are extremely rare, hence vaginismus is mostly treated with psychotherapy.

Miscarriage is a pregnancy that ends spontaneously before the foetus reaches the age of viability i.e. before 24 weeks of gestation. In a threatened miscarriage the USG findings are of a foetus present in the uterus and on speculum examination the cervical OS is closed, in an inevitable miscarriage the cervical OS is opened. In an incomplete miscarriage the uterus contains the retained products of conception and the cervical OS is open. complete miscarriage contains no retained products of conception and the cervix is closed as the bleeding as resolved.

Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.

Firstline medical management of PCOS is with clomiphene.

Ovulation Disorders

WHO Group I : Hypothalamic pituitary failure (Stress, anorexia, exercise induced)
Management:
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation

WHO Group II : Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Management:
Weight reduction if BMI >30
Clomiphene/Clomiphene (1st line)
Metformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)

WHO Group III : Ovarian failure
Management:
Consider IVF with donor eggs

Multiple pregnancy is considered a high risk for obstetric complications such as spontaneous abortion, hypertensive disorders, placenta previa, and fetal malformations. Specifically, the incidence of hypertensive disorders, a common source of maternal morbidity, is 15% to 35% in twin pregnancies, which is two to five times higher than in singleton pregnancies. Additionally, the aetiology of preterm birth is not completely understood, but the association between multiple pregnancy and preterm birth is well known. A secondary analysis of the WHO Global Survey dataset indicated that 35.2% of multiple births were preterm (< 37 weeks gestation); of all multiple births, 6.1% of births were before 32 weeks gestation, 5.8% were during weeks 32 and 33, and 23.2% were during weeks 34 through 37

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.

Her T-score puts her in the osteopenic range. The presence of fragility fractures is more important in the osteoporotic patient. Olecranon fracture is not a typical fragility fracture.

It is important to be aware of the difference between management of simple hypertension and pre-eclampsia in pregnancy. A BP of 140/90 to 149/99 mmHg is classed as mild hypertension. Without proteinuria this can be monitored once weekly and the patient can be discharged. If proteinuria is present with any degree of hypertension the patient requires admission and BP should be monitored at least 4 times daily according to NICE guidance.