An ultrasonography is performed for confirmation, as well as for the evaluation of maternal pelvis, fetal size and viability in cases were breech presentation is suspected on manual examination. As there is a chance for spontaneous correction of breech presentation into cephalic during 36 to 37 weeks, this should be considered in every future visit. The chances for spontaneous version reduces to 25% if breech position persists beyond this period of time.

It an external cephalic version should be offered to all women with breech presentation, provided there are no contraindications or indication for cesarean delivery due to other reasons.

If a patient presents with PROM at 27 weeks of gestation, her management plan would have to include:

1) Cervical swabs to rule out infection
2) Commencement of prophylactic antibiotics such as erythromycin until results from the swabs are available
-If only normal vaginal flora are seen, prophylactic antibiotics can be stopped.
3) Administration of glucocorticoid- usually for 48 hours to promote maturity of the fetal lung and lower the chance of intracranial bleeding if the foetus has to be delivered prematurely
4) Transfer to a healthcare centre that has neonatal intensive care facilities to ensure if intensive care is needed post-delivery, the healthcare staff are prepared
5) Blood profile (particularly white cell count) and inflammatory markers (CRP) to look for any signs of chorioamnionitis
6) CTG assessment every 2-3 days. Abnormalities found on the CTG tracing are often the first evidence of problems such as a subclinical chorioamnionitis
7) Tocolysis with tocolytics such as IV salbutamol or nifedipine if contractions start before the course of glucocorticoid therapy is finished. Post-glucocorticoid therapy, tocolysis would not be often employed since there is a risk of masking contractions that occur due to an infection. In those cases, it is better to deliver the baby rather than to prolong the pregnancy. If there is no infection, the management plan should aim to prolong the pregnancy and delay delivery of a very premature baby.

Uterine surgical history & scope of vaginal birth are as follows:
– In case of low transverse cesarean delivery with horizontal incision: trial of labor is not contraindicated.
– Classical cesarean delivery with vertical incision: trial of labor is contraindicated
– Abdominal myomectomy with uterine cavity entry: trial of labor is contraindicated
– Abdominal myomectomy without uterine cavity entry: trial of labor is not contraindicated.

In laboring patients with prior uterine surgical histories like a prior classical (vertical) cesarean delivery or a prior myomectomy that was extensive or has entered the uterine cavity like during removal of intramural or submucosal fibroids are at a higher risk for uterine rupture. Given this patient’s history of previous myomectomy, her intense and constant abdominal pain with an abnormal fetal heart rate tracing, like persistent variable decelerations, are pointing to uterine rupture. vaginal bleeding, abdominally palpable fetal parts, loss of fetal station and any change in contraction pattern are the other possible manifestations of uterine rupture. Based on the extent and exact location of the rupture and the presence or absence of regional anesthesia, presentation of a uterine rupture will change.

Vaginal delivery is safe after a low transverse (horizontal uterine incision) cesarean delivery. Patients with a history of either classical cesarean delivery or an extensive myomectomy are delivered via cesarean delivery at 36-37 weeks gestation, so urgent laparotomy and cesarean delivery are required if these patients present in labor. Further management is determined by other intraoperative findings like, whether uterine rupture has occurred, if occured then delivery is done through the rupture site, followed by a uterine repair; If the uterus is unruptured, a hysterotomy (ie, cesarean delivery) is performed. In patients with prior classical cesarean delivery or extensive myomectomy, an expectant management for a vaginal delivery is contraindicated.

Amnioinfusion is the technique of placing an intrauterine pressure catheter to decrease umbilical cord compression by doing an intrauterine infusion and this thereby helps to resolve variable decelerations. In patients with a history of uterine surgery Amnioinfusion is contraindicated.

In cases with abnormal fetal heart rate tracings, if the patient is completely (10cm) dilated, an operative vaginal delivery can be performed to expedite a vaginal delivery.

Terbutaline is a tocolytic, which is administered to relax the uterus in conditions with contractile abnormalities, such as tachysystole which presents with >5 contractions in 10 minutes or tetanic contractions were contractions last for >2 minutes, which results in fetal heart rate abnormalities. In the given case, the patient’s contractions are normal, which occurs in every 2-3 minutes and lasts for 45 seconds, causing pain and cervical dilation.

After a classical cesarean delivery or an extensive myomectomy, labor and vaginal delivery are contraindicated due to its significant risk of uterine rupture. Laparotomy and cesarean delivery are preferred in laboring a patients at high risk of uterine rupture.

Clotting factor problem. Some of the more common disorders of coagulation that occur during pregnancy are von Willebrand disease, common factor deficiencies, platelet disorders and as a result of anticoagulants.

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.

During pregnancy, the chances for a woman to develop oral candidiasis double. An aphthous ulcer has a yellowish floor which is surrounded by an erythematous halo while in lichen planus, the lesions do not have the appearance of a thick white mark but are more or less lace-like. The lesions in leucoplakia have raised edges and they appear as bright white patches which are sharply defined and cannot be rubbed out. Smoking may affect the tongue, producing tongue coating. In this case the tongue is just inflamed which is a sign of infection.

Twin gestations are generally at increased risk of complications and this risk is further stratified based on the chorionicity ie. number of placentas and amnionicity, the number of amniotic sacs of the gestation. In the given case patient has monochorionic diamniotic twins, which means 1 placenta and 2 amniotic sacs, based on the presence of 2 embryos, a single placenta and a thin intertwin membrane composed of 2 amniotic sacs that meets the placenta at a 90-degree angle (“T sign”). In patients who appear to have a single placenta, the base shape of the intertwin membrane distinguishes between a monochorionic (“T sign”) and fused dichorionic (“lambda sign”) gestation.
Monochorionic twins are at high risk for twin-twin transfusion syndrome (TTTS), which is a complication that can result in heart failure and fetal
eonatal mortality in both twins. In TTTS, unbalanced arteriovenous anastomoses are present between the shared placental vessels that supply the twins, because of these anastomoses, blood from the placental arteries from one twin (donor), which is of high resistance/pressure, is shunted into the placental veins of the other twin (recipient) with low resistance/pressure. This shunting of blood away from the donor twin causes anemia that leads to renal failure, oligohydramnios, low-output heart failure, and fetal growth restriction. In contrast, the shunting of blood toward the recipient twin causes polycythemia, which leads to polyhydramnios, cardiomegaly, high-output heart failure and hydrops fetalis. This in turn makes both twins at high risk for intrauterine and neonatal death.
Mild TTTS is expectantly managed with serial ultrasounds to evaluate for worsening clinical features, whereas moderate-to-severe cases are treated with laser coagulation of the placental anastomoses.

In monozygotic twins, placentation type is determined by timing of the twinning.  Twinning that occurs shortly after fertilization yields a dichorionic diamniotic gestation.  In contrast, the incomplete division (ie, fission) that can lead to conjoined twins occurs later in development and yields a monochorionic monoamniotic gestation. As the twins are in the same sac, monochorionic monoamniotic gestations can be complicated by cord entanglement but not possible in the given case as this patient has diamniotic twins.

Risk factors for placenta accreta, implantation of the placenta directly into the myometrium, include placenta previa and prior uterine surgeries like cesarean delivery, myomectomy, etc

Twin pregnancies are at increased risk of placenta previa (placental tissue that covers the internal cervical os); however, this patient has a fundal placenta, making this complication unlikely.

Monochorionic twin gestations can be complicated by twin-twin transfusion syndrome, which is potentially a fatal condition that results from unbalanced vascular anastomoses between the vessels supplying umbilical cords of each twin.

The drug of choice for eclampsia and pre-eclampsia is magnesium sulphate. It is given as a loading dose of 4g i/v over 5 minutes, followed by an infusion for the next 24 hours at the rate of 1g/hr. If the seizures are not controlled, an additional dose of MgSO4 2-4gm i/v can be given over five minutes. Patients with eclampsia or pre-eclampsia can develop any of the following symptoms: persistent headache, visual abnormalities like photophobia, blurring of vison or temporary blindness, epigastric pain, dyspnoea and altered mental status.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

Expectant management has been reported with unpredictable success rate ranging from 25–76%. Waiting for spontaneous expulsion of the products of conception would waste much time, during which women may suffer uncertainty and anxiety. However, when additional surgical evacuation is needed owing to failure, they may suffer from an emotional breakdown. It is thus not recommended for missed early miscarriage due to the risks of emergency surgical treatment and blood transfusion.

Incoordinate uterine action almost always results in fetal distress due to increased resting intrauterine pressure. All other statements can also cause fetal distress, however, these are not as common as incoordinate uterine action. Syntocin infusion for labour augmentation and administration of epidural anaesthetic for pain relief can also increase the risk of fetal distress.
Cardiotocograph (CTG) monitoring during labour is highly recommended in patients where the fetal head is found in the OP position. Moreover, it is mandatory when there is Syntocin infusion or epidural anaesthesia.

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

In severe cases of hyperemesis, complications include vitamin deficiency, dehydration, and malnutrition, if not treated appropriately. Wernicke encephalopathy, caused by vitamin-B1 deficiency, can lead to death and permanent disability if left untreated. Additionally, there have been case reports of injuries secondary to forceful and frequent vomiting, including oesophageal rupture and pneumothorax.

Electrolyte abnormalities such as hypokalaemia can also cause significant morbidity and mortality. Additionally, patients with hyperemesis may have higher rates of depression and anxiety during pregnancy.

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.

The Australasian Diabetes in Pregnancy Society recommends a 50 or 75 g glucose challenge at 26–28 weeks in all pregnant women. An OGTT should be performed if the test result is abnormal: 1 hour values after a 50 or 75 g glucose challenge exceeding 7.8 or 8.0 mmol/L respectively.

If a woman has had gestational diabetes, a repeat OGTT is recommended at 6–8 weeks and 12 weeks after delivery. If the results are normal, repeat testing is recommended between 1 and 3 years depending on the clinical circumstances.

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to rapid and severe haemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labour or rapid forceful labour, especially if stimulated.

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.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia. There is no consensus on specific diagnostic criteria, but it generally refers to the severe end of the spectrum regarding nausea and vomiting in pregnancy.

Hormone changes wherein hCG levels peak during the first trimester corresponds to the typical onset of hyperemesis symptoms. It is well-known that the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.

Hyperemesis gravidarum refers to extreme cases of nausea and vomiting during pregnancy. The criteria for diagnosis include vomiting that causes significant dehydration (as evidenced by ketonuria or electrolyte abnormalities, and the dry with coated tongue) and weight loss (the most commonly cited marker for this is the loss of at least five percent of the patient’s pre-pregnancy weight) in the setting of pregnancy without any other underlying pathological cause for vomiting.

Placental abruption is defined as the premature separation of placenta from uterus and the condition usually presents with bleeding, uterine contractions and fetal distress. It is one of the most significant cause of third-trimester bleeding and is often associated with fetal and maternal mortality and morbidity. In all pregnant women with vaginal bleeding in the second half of the pregnancy, this condition should be considered as a differential diagnoses.
Though vaginal bleeding is the most common presenting symptom reported by almost 80% of women with placental abruption, vaginal bleeding is concealed in 20% of women with placental abruption, therefore, absence of vaginal bleeding does not exclude placental abruption.

Symptoms and complications of placental abruption varies according to patient, frequency of appearance of some common features is as follows:
‌- Vaginal bleeding is the common presentation in 80% of patients.
‌- Abdominal or lower back pain with uterine tenderness is found in 70%
‌- Fetal distress is seen in 60% of women.
‌- Abnormal uterine contractions like hypertonic, high frequency contractions are seen in 35% cases.
‌- Idiopathic premature labor in 25% of patients.
‌- Fetal death in about 15% of cases.

Examination findings include vaginal bleeding, uterine contractions with or without tenderness, shock, absence of fetal heart sounds and increased fundal height due to an expanding hematoma. Shock is seen in class 3 placental abruption which represents almost 24% of all cases of placental abruption.

The most consistent finding in obstructed labour is a 4cm head that is palpable on the abdomen. The bony part is usually palpated at the level of the ischial spine on pelvic examination.
When prolonged labour is suspected, a pelvic vaginal examination helps to differentiate obstructed labour from inefficient/incoordinate labour.

Findings in a pelvic examination:
Obstructed labour
moulding of fetal head ++
caput formation on the fetal head ++
cervical oedema – anterior lip oedema
fetal tachycardia ++
station of the head (relation to lowest part of ischial spines) – just at or above the IS
amount of head palpable above the pelvic brim when the lowest point of the head is at the IS – > 2 finger breadths (FB)

Inefficient or incoordinate labour
moulding of fetal head usually none
caput formation on fetal head +
absent cervical oedema
fetal tachycardia +
station of the head (relation to lowest part of ischial spines) – can be above or below IS
amount of head palpable above the pelvic brim when the lowest point of the head is at the IS – < 1 finger breadth (FB).

Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

Magnesium Sulphate is the drug of choice in eclamptic patients. A loading dose of 4g magnesium sulphate in 100mL 0.9% saline IVI over 5min followed by maintenance IVI of 1g/h for 24h. Signs of toxicity include respiratory depression and jerky tendon reflexes. In recurrent fits additional 2g can be given. Magnesium should be stopped when the respiratory rate is <14/min, absent tendon reflexes, or urine output is <20mL/h.

The next best line of management is immediate delivery via Caesarean section ( C section).

This is because of the change in cardiotocography (CTG). The pattern became much more severe with a virtual lack of short-term variability and prolonged decelerations. These changes indicate the necessity for an immediate C section as the cervix is not fully dilated.

As immediate delivery is indicated, another pH assessment is unnecessary as it would delay delivery and increase the likelihood of fetal hypoxia.

Delivery by ventose, in a primigravida where the cervix is only 8cm dilated is not indicated as it would allow the labour to proceed or augmenting with Syntocinon.

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.

Alcohol exposure during pregnancy results in impaired growth, stillbirth, and fetal alcohol spectrum disorder. Fetal alcohol deficits are lifelong issues with no current treatment or established diagnostic or therapeutic tools to prevent and/or ameliorate some of these adverse outcomes.

Alcohol readily crosses the placenta with fetal blood alcohol levels approaching maternal levels within 2 hours of maternal intake. As there is known safe level of alcohol consumption during pregnancy, and alcohol is a known teratogen that can impact fetal growth and development during all stages of pregnancy, the current recommendation from the American College of Obstetricians and Gynaecologists, Centre for Disease Control (CDC), Surgeon General, and medical societies from other countries including the Society of Obstetricians and Gynaecologists of Canada all recommend complete abstinence during pregnancy.

Atenolol is considered teratogenic and has two main risks: fetal bradycardia and neonatal apnoea. ACE inhibitors and angiotensin II receptor blockers are also known to be teratogenic (even though large-scale studies are difficult to conduct during pregnancies).

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.