Trichomoniasis is caused by trichomonas. It is sexually transmitted. It is diagnosed on microscopy of vaginal discharge and cultured in Finn-Berg Whittington medium. It is characterised by valval itching, foul smelling discharge and appearance of strawberry cervix due to presence of punctate haemorrhages which occur in 2% of the cases.

Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.

In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.

The internal anal sphincter is innervated by pelvic splanchnic nerves

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.

PMNs phagocytise debris and kill bacteria via free radicals (AKA respiratory burst). They also break down damaged tissue. PMNs typically undergo apoptosis after 48 hours. They are then engulfed and degraded by macrophages. Macrophages therefore become the predominant cell type in the wound on days 3-4.

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface, resulting in a local inflammatory response and, in later pregnancy, thrombosis of the uteroplacental vasculature. This patient should be offered referral to a specialist clinic as she has had recurrent miscarriages. Low dose aspirin is one of the treatment options to prevent further miscarriage for patients with antiphospholipid syndrome.

The following hormones are excreted from the anterior pituitary gland: TSH, GN, ACTH, LH, FSH, MSH, PRL.
Human chorionic gonadotropin (hCG, or human chorionic gonadotrophin) is a placental hormone secreted by syncitiotrophoblasts during the second week of gestation.

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.

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

This patient has been unable to conceive for over a year, and her fallopian tubes are blocked. Her body mass index is 42.
Because she has obstructed Fallopian tubes, in-vitro fertilisation (IVF) is an alternative to getting pregnant for this patient.
A woman with a BMI over 35, on the other hand, will need twice as many IVF rounds to conceive as a woman of normal weight.
As a result, the greatest advise for successful IVF would be to decrease weight as the first step in management.
Obese (BMI less than 40) patients’ IVF success chances are reduced by 25% and 50%, respectively.

Fetal Blood Sampling (FBS) should only be performed when the cervix is >3cm dilated.

Indications for FBS:
1. Pathological CTG in labour
2. Suspected acidosis in labour

Contraindications to FBS
– Maternal infection e.g. HIV, HSV and Hepatitis
– Known fetal coagulopathy
– Prematurity (< 34 weeks gestation)
– Acute fetal compromise

Interpretation of FBS results:
pH >7.25 = Normal -Repeat in 1 hour if CTG remains abnormal
7.21 to 7.24 = Borderline – Repeat in 30 minutes
<7.20 = Abnormal - Consider delivery

During the first 8 weeks of pregnancy, concentrations of hCG in the blood and urine usually double every 24 hours. Levels of the hormone typically peak at around 10 weeks, decline until 16 weeks, then remain constant.

The history is typical of Intrahepatic Cholestasis of Pregnancy, also known as obstetric cholestasis and prurigo gravidarum. It is characterised by itching without rash and abnormal LFTs beyond normal pregnancy ranges. Itching affects around 23% of pregnancies and can occur before biochemical changes.

The period from attaining a complete cervical dilation of 10 cm to fetal delivery is considered as the second stage of labor. In the given case patient have achieved an excellent fetal descent to +3 due to her average-sized infant of 3.4 kg, suitable pelvis (no fetal molding or caput, suggesting no resistance against the bony maternal pelvis), and a favorable fetal position of left occiput anterior. 
But with no further fetal descent the patient fulfills the following criterias suggestive of second-stage arrest like:
≥3 hours of pushing in a primigravida without an epidural or ≥4 hours pushing with an epidural, as in this patient
OR
≥2 hours of pushing in a multigravida without an epidural or ≥3 hours pushing with an epidural.

As continued pushing without any effect will lead to complications like postpartum hemorrhage, limiting the chances of spontaneous vaginal delivery, it is better to manage this case by operative vaginal delivery procedures like vacuum-assisted delivery, to expedite delivery. maternal exhaustion, fetal distress, and maternal conditions like hypertrophic cardiomyopathy, in which the Valsalva maneuver is not recommended are the other indications for performing an operative vaginal delivery.

Fundal pressure is the technique were external pressure is applied to the most cephalad portion of the uterus, were the applied force is directed toward the maternal pelvis. The maneuver was not found to be useful in improving the rate of spontaneous vaginal deliveries.

Epidurals will not arrest or affect spontaneous vaginal delivery rates, instead they just lengthen the second stage of labor. Also an appropriate analgesia is a prerequisite to use in operative vaginal delivery.

Manual rotation of an infant to a breech presentation for breech vaginal delivery is called as internal podalic version. It is contraindicated in singleton deliveries due to the high risk associated with breech vaginal delivery in regards to neonatal mortality and morbidity.

The ideal fetal head position in vaginal delivery is occiput anterior (OA) as the flexed head in this provides a smaller diameter and facilitates the cardinal movements of labor. The occiput posterior (OP) position, in contrast to OA, presents with a larger-diameter head due to the deflexed position. So the chance for spontaneous vaginal delivery will be decreased if fetal head is rotated to OP position.

A lack of fetal descent after ≥4 hours of pushing in a primigravida with an epidural (≥3 hours without) or ≥3 hours in a multigravida with an epidural (≥2 hours without) is defined as second stage arrest of labor.  The condition is effectively managed with operative vaginal delivery procedures like vacuum-assisted delivery. Other common indications for operative vaginal delivery are maternal exhaustion, fetal distress, and maternal conditions where the Valsalva maneuver is not recommended.

The incubation period of varicella is 10-21 days.

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.

The ultrasound used a frequency of 3.5-7 MHz emitted from a transducer.

Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.

The World Health Organisation defines the maternal mortality ratio as the number of maternal deaths during a given period per 100,000 live births during the same period. This measure indicates the risk of death in a single pregnancy.

Primary hyperparathyroidism is the most common cause of hypercalcaemia with incidence rates in the UK approximately 30 per 100,000 The majority of patients are postmenopausal women.

TORCH infections are responsible for perinatal complications. CMV is the most common amongst them. Primary infection often produces no symptoms or mild non-specific flu-like symptoms in the mother. The diagnosis is often made after abnormalities are seen in the foetus on ultrasound scan. The main features seen in an affected foetus are FGR, microcephaly, ventriculomegaly, ascites or hydrops. Some foetuses which are infected may not show any features on ultrasound, but may later be found to have neurological damage such as blindness, deafness or developmental delay. The neonate can also be anaemic and thrombocytopenic, with hepatosplenomegaly, jaundice and a purpureal rash.

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

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

Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.

Due to the previous history of caesarean section, uterine rupture would be the most likely cause of bleeding in this patient who is at a prolonged active phase of first stage of labour.

Maternal manifestations of uterine rupture are highly variable but some of its common features includes:
– Constant abdominal pain, where the pain may not be present in sufficient amount, character, or location suggestive of uterine rupture and may be masked partially or completely by use of regional analgesia.
– Signs of intra abdominal hemorrhage is a strong indication. Although hemorrhage is common feature, but signs and symptoms of intra-abdominal bleeding in cases of uterine rupture especially in those cases not associated with prior surgery may be subtle.
– Vaginal bleeding is not considered as a cardinal symptom as it may be modest, despite major intra-abdominal hemorrhage.
– Maternal tachycardia and hypotension
– Cessation of uterine contractions
– Loss of station of the fetal presenting part
– Uterine tenderness
As seen in this case, fetal bradycardia is the most common and characteristic clinical manifestation of uterine rupture, preceded by variable or late decelerations, but there is no other fetal heart rate pattern pathognomonic of rupture. Furthermore, fetal heart rate changes alone have a low sensitivity and specificity for diagnosing a case as uterine rupture.
Pain and persistent vaginal bleeding despite the use of uterotonic agents are characteristic for postpartum uterine rupture. If the rupture extends into the bladder hematuria may also occur.
A definite diagnosis of uterine rupture can be made only after laparotomy. Immediate cesarean section should be performed to save both the mother and the baby in cases where uterine rupture is suspected.

Placenta previa typically presents with painless bright red vaginal bleeding usually in the second to third trimester. Although it’s a condition that sometimes resolves by itself, bleeding may result in serious complications for the mother and the baby and so it should be managed as soon as possible.

Turner syndrome patients have malfunctioning or streak ovaries due to which they can never conceive. It affects females, who will have a short stature, widely spaced nipples, webbed neck and karyotyping shows 45XO.

Mullerian agenesis occurs in 1 in 5000 to 1 in 40000 girls. The Mullerian system does not develop which results in an absent uterus and upper vagina. This condition is also known as Rokitansky-Kuster-Hauser syndrome, The ovarian function is normal and so the most common presentation is amenorrhea in the presence of an otherwise normal pubertal development.

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.

Thyroxine requirement during pregnancy will increases by 25 to 30 percent, which is seen as early as fifth week of pregnancy.

Children born to those women whose hypothyroidism was inadequately treated during pregnancy, are at higher risk for developing neuropsychiatric impairments.

When a woman who is on thyroxine is planning to conceive, they are advised to increase their thyroxine dose by 30 percent at the time of confirmation of pregnancy.

During pregnancy TSH also should be monitored at every 8 to 10 weeks, with necessary dose adjustments.

Dose requirements of thyroxine will return to pre-pregnancy level soon after delivery and it will not change according to whether the mother is breastfeeding or not.

The woman’s blood pressure was elevated at her visit; therefore she should be advised to immediately cease the oral contraceptive pill (OCP) so that the hypertension can resolve without the need for any hypotensive treatment. The blood pressure can then be reassessed in three months. Alternative, non-hormonal birth control methods such as condoms should be used instead.

If her high blood pressure does not resolve, any medication that would be commenced to reduce her blood pressure should be one that is safe to continue when she becomes pregnant.

It is inappropriate to continue the OCP even at a lower dosage or in combination with a hypotensive agent.

Methyldopa has been evaluated and used for treatment of hypertension during pregnancy. There is no clinical evidence to suggest that it causes harm to the foetus or neonate.

Angiotensin converting enzyme (ACE) inhibitors are not approved for use in pregnancy as they have been associated with fetal death in utero. Other antihypertensive agents such as beta-blockers and diuretics are also problematic in pregnancy and should be avoided.

The properties of oestrogen:
Structure: Stimulates endometrial growth, maintenance of vessels and skin,
reduces bone resorption, increases bone formation, increases uterine growth
Protein synthesis: Increases hepatic synthesis of binding proteins
Coagulation: Increases circulating levels of factors II, VII, IX, X, antithrombin III and plasminogen; increases platelet adhesiveness
Lipid: Increases HDL and reduces LDL,increases triglycerides, reduces
ketone formation, increases fat deposition
Fluid balance: Salt and water retention
Gastrointestinal: Reduces bowel motility, increases cholesterol in bile

Organisms frequently associated with obstetric sepsis include: beta haemolytic streptococci, Gram-negative rods such as Escherichia coli, Streptococcus pneumoniae and influenza A and B.

E. coli is the most common sepsis pathogen in pregnancy.

it is imperative to elucidate the patient’s risk for current pregnancy and time within her current menstrual cycle prior to IUD insertion. A negative urine pregnancy test is a prerequisite to placement of an IUD. Pregnancies occurring with IUDs in place have an increased incidence of complications, including spontaneous abortion and septic abortion.

For this reason, many providers prefer to time IUD insertion within the first 5-7 days of the menstrual cycle, further assuring that the patient is not newly pregnant.

All other options take risk of the patient being pregnant.

Boundaries of the Femoral Triangle: Superior: Inguinal ligament Medial: Medial border of the adductor longus Lateral: Medial border of the sartorius Floor: Pectineus, Adductor longus and Iliopsoas muscles Roof: Fascia Lata (cribriform fascia at the saphenous opening) Trasversalis fascia forms part of the roof of the inguinal canal

The pelvic skeleton is formed posteriorly (in the area of the back), by the sacrum and the coccyx and laterally and anteriorly (forward and to the sides), by a pair of hip bones. Each hip bone consists of 3 sections, ilium, ischium, and pubis.

At the 36‑week appointment, all pregnant women should be seen again. At this appointment: measure blood pressure and test urine for proteinuria; measure and plot symphysis–fundal height; check position of baby; for women whose babies are in the breech presentation, offer external cephalic version (ECV)

The most appropriate test for a hydatiform mole is serum beta hCG levels, which are consistently raised in these patients. The levels return to normal when the pregnancy is terminated.

Pulmonary embolism (PE) is a treatable disease caused by thrombus formation in the lung-vasculature, commonly from the lower extremity’s deep veins compromising the blood flow to the lungs.
Computed tomography of pulmonary arteries (CTPA) and ventilation-perfusion (V/Q) scan are the two most common and widely practiced testing modalities to diagnose pulmonary embolism.

Pulmonary ventilation (V) and Perfusion (Q) scan, also known as lung V/Q scan, is a nuclear test that uses the perfusion scan to delineate the blood flow distribution and ventilation scan to measure airflow distribution in the lungs. The primary utilization of the V/Q scan is to help diagnose lung clots called pulmonary embolism. V/Q scan provides help in clinical decision-making by evaluating scans showing ventilation and perfusion in all areas of the lungs using radioactive tracers.

Ventilation-perfusion V/Q scanning is mostly indicated for a patient population in whom CTPA is contraindicated (pregnancy, renal insufficiency CKD stage 4 or more, or severe contrast allergy) or relatively inconclusive.

The round ligament develops from the lower end of the gubernaculum in females. In the males it persists as the scrotal ligament.

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.

From the options given, option A is correct as primary pulmonary hypertension is considered a contraindication to pregnancy.
The patient should be educated about the possible risks and increased maternal mortality in such cases. This restriction is due to the fact that symptoms of Pulmonary hypertension gets worse during pregnancy which results in high maternal mortality.
Termination of pregnancy may be advisable in these circumstances mostly to preserve the life of the mother.
Sudden death secondary to hypotension is also a commonly dreaded complication among patients with pulmonary hypertension during pregnancy.

This patient presenting with oligohydramnios in her third trimester and had reported an episode of sudden gush of fluid secondary to ruptured membrane which she had mistaken to be “urinary incontinence”.  Hence, the most likely cause of oligohydramnios in this patient will be premature preterm rupture of membrane (PPROM).

An amniotic fluid volume which is less than expected for gestational age is called as Oligohydramnios and is typically diagnosed by ultrasound examination. This condition can be qualitatively described as reduced amniotic fluid volume and quantitatively as amniotic fluid index ≤5 cm or a single deepest pocket <2 cm. Oligohydramnios either can be idiopathic or may have a maternal, fetal or placental cause. Fetal prognosis in this case depends on several factors like the underlying cause, the severity of loss ie. reduced versus no amniotic fluid state and the gestational age at which oligohydramnios occurred. As an adequate volume of amniotic fluid is critical for the normal fetal movements, for fetal lung development and for cushioning the fetus and umbilical cord from uterine compression, so pregnancies complicated with oligohydramnios are at higher risk for fetal deformation, pulmonary hypoplasia and umbilical cord compression.
Oligohydramnios is also associated with an increased risk for fetal or neonatal death, which can either be related to the underlying cause of reduction in amniotic fluid volume or due to the sequelae caused due to reduced amniotic fluid volume. The amniotic fluid volume reflects the balance between fluid production and movement of fluid out of the amniotic sac and the most common mechanisms behind oligohydramnios are fetal oliguria/anuria or fluid loss due to rupture of membranes; also reduction in the amount of lung fluid or increased swallowing do not play major roles in this. Idiopathic cases as in idiopathic oligohydramnios, may be due to alterations in the expression of water pores like aquaporin 1 and aquaporin 3, present in fetal membranes and placenta.

Causes of oligohydramnios
a) Maternal causes includes:
– Medical or obstetric conditions associated with uteroplacental insufficiency like preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia.
– Intake of medications like angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab.
b) Placental causes are:
– Abruption of placenta
– Twin polyhydramnios-oligohydramnios sequence which is the Twin to twin transfusion
– Placental thrombosis or infarction
c) Fetal cases leading to oligohydramnios are:
– Chromosomal abnormalities
– Congenital abnormalities which are associated with impaired urine production
– Growth restriction
– Demise
– Post-term pregnancy
– Ruptured fetal membranes
– Infections
– Idiopathic causes

During First trimester: Etiology of oligohydramnios during the first trimester is often unclear. As the gestational sac fluid is primarily derived from the fetal surface of the placenta via transamniotic flow from the maternal compartment and secretions from the surface of the body of the embryo reduced amniotic fluid prior to 10 weeks of gestation is rare.

During Second trimester: Fetal urine begins to enter the amniotic sac and fetus begins to swallow amniotic fluid by the beginning of second trimester, therefore, during this period any disorders related to the renal/urinary system of the fetus begins to play a prominent role in the etiology of oligohydramnios. Some of such anomalies include intrinsic renal disorders like cystic renal disease and obstructive lesions of the lower urinary tract like posterior urethral valves or urethral atresia. Other common causes of oligohydramnios in the second trimester are maternal and placental factors and traumatic or nontraumatic rupture of the fetal membranes.

During Third trimester: Oligohydramnios which is first diagnosed in the third trimester is often associated with PPROM or with conditions such as preeclampsia or other maternal vascular diseases leading to uteroplacental insufficiency. Oligohydramnios frequently accompanies fetal growth restriction as a result of uteroplacental insufficiency.

Clomiphene is a non-steroidal compound with tissue selective actions. It is used to induce ovulation in women who wish to become pregnant. It is a selective oestrogen receptor modulators.

Contraindications to tocolysis in preterm labor are as follows:
– Gestational age > 34 weeks or <24 weeks
– Labor is too advanced with an advanced cervical dilation of >4 cm
– Abnormal CTG suggesting a non-reassuring fetal status
– Lethal fetal anomalies
– Intrauterine fetal demise
– Suspected fetal compromise
– Significant antepartum hemorrhage, such as placental abruption/ active vaginal bleeding with hemodynamic instability
– Any suspected intrauterine infections like chorioamnionitis
– Maternal hypotension
– Pregnancy-induced hypertension/ eclampsia/ pre-eclampsia
– Placenta previa
– Placental insufficiency
– Intrauterine growth retardation
– Maternal allergy to specific tocolytic agents or cases where tocolytics are contraindicated due to specific comorbidities like in case of cardiac disease, were beta agonists cannot be administered.

As there are nonpulmonary morbidities associated with preterm birth, fetal pulmonary maturity, known or suspected, is not an absolute contraindication for tocolysis. These fetuses could potentially benefit from prolongation of pregnancy and from the nonpulmonary benefits of glucocorticoid therapy.

When cervical dilation is greater than 3 cm inhibition of preterm labor is less likely to be successful. In such cases Tocolysis can be considered when the goal is to administer antenatal corticosteroids or to safely transport the mother to a tertiary care center.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication to suppression of labor.

Lower abdominal pain during menstrual periods and lower back or leg pain are associated with endometriosis in the uterosacral ligaments. Endometriosis can cause diarrhoea and IBS type symptoms. Note Endometriosis on the uterosacral ligament can cause tender nodules to form. These can be palpated during pelvic exam. Tender nodules are specific to endometriosis of the uterosacral ligament so if the question mentions feeling a tender nodule during PV exam think endometriosis of the Uterosacral ligaments!

The neck of the bladder is surrounded by the internal sphincter. It is supplied by the sympathetic and parasympathetic nerves of the splanchnic nerve. Parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. It Is predominantly by the parasympathetic nerves S2-S4. Relaxation of the bladder is caused by inhibiting the sacral parasympathetic preganglionic neurons and exciting the lumbar sympathetic preganglionic neurons. Remember SYMPATHETIC is for STORAGE and PARASYMPATHETIC is for PEEING.

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.

Turner syndrome patients have high FSH levels and low oestrogen levels. They have a short stature and buccal smear is chromatin negative.

The basic components of the mammary gland are the alveoli. These are lined with milk-secreting cuboidal cells surrounded by myoepithelial cells. The alveoli join to form groups known as lobules. The lobules form lobes. Each lobe has a lactiferous duct that drains into openings in the nipple. Each breast typically contains 15-20 lobes.

Premenstrual dysphoric disorder (PMDD) is a more serious form of premenstrual syndrome (PMS). PMS causes bloating, headaches, and breast tenderness a week or two before your period.

With PMDD, you might have PMS symptoms along with extreme irritability, anxiety, or depression. These symptoms improve within a few days after your period starts, but they can be severe enough to interfere with your life.

PMDD symptoms appear a week or two before menstruation and go away within a few days after your period starts. In addition to PMS symptoms, you may have:

Anger or irritability.
Anxiety and panic attacks.
Depression and suicidal thoughts.
Difficulty concentrating.
Fatigue and low energy.
Food cravings or binge eating.
Headaches.
Insomnia.
Mood swings.

The following treatments have been shown to relieve symptoms:

Sertraline, escitalopram, paroxetine, and fluoxetine are SSRIs (selective serotonin reuptake inhibitors). SSRIs are the first-line treatment and are extremely effective.
The second line of defence is alprazolam (a short course recommended due to its addictive potential).
The use of temazepam has little advantage because it only aids with sleep and is relatively short-acting.
Lifestyle modifications-weight loss, exercise, quitting smoking, and relaxation therapies for less severe PMS.
Danazol-suppresses the ovulation and helps with mastalgias associated with PMS.