The anal sphincters are responsible for closing the anal canal to the passage of faeces and flatus. The smooth muscle of the involuntary internal sphincter sustains contraction to prevent the leakage of faeces between bowel movements and is innervated by the pelvic splanchnic nerves, which are a branch of the spinal segment 4. The external sphincter is made up of skeletal muscle and can therefore contract and relax voluntarily. Its innervation comes from the inferior rectal branch of the pudendal nerve, and the perineal branch of S4 nerve roots.

Ovarian insufficiency is a failure of the ovary to function adequately in a woman younger than 40 years, in its role either as an endocrine organ or as a reproductive organ. In women aged 40 years or older, the expected physiologic decline of ovarian function that takes place with aging is termed perimenopause or the menopausal transition.
Medical treatment of patients with primary ovarian insufficiency should address the following aspects:

Ovarian hormone replacement
Restoration of fertility
Psychological well-being of the patient

It is not appropriate to give this patient contraceptive pills since she desires pregnancy.

There is no evidence that Danazol or Metformin would improve ovarian follicle function.

Common risk factors for Rectovaginal fistula are Pelvic radiation, Obstetric trauma, Pelvic surgery, Colon cancer, Diverticulitis and Crohn disease. Uncontrollable passage of gas &/or feces from the vagina is considered the common clinical feature of Rectovaginal fistula.
Diagnosis is done with the help of physical examination, fistulography, Magnetic resonance imaging and Endosonography.

This patient, mentioned in the case, presents with malodorous vaginal discharge (ie, stool), gas passing through the vagina, and a posterior vaginal lesion most likely has a rectovaginal fistula, which is an aberrant connection between bowel and vagina.  Although development of rectovaginal fistula is commonly associated with obstetric trauma or pelvic surgery, patients without these risk factors are recommended to be evaluated for other additional causes like gastrointestinal conditions.
This patient’s intermittent, crampy abdominal pain and perianal sinus in the setting of a rectovaginal fistula is most likely due to an underlying Crohn disease.  Crohn disease, is a transmural inflammation of the gastrointestinal tract, which predisposes patients to bowel abscess, fissure, and fistula formation.  Although the rectum is typically spared in Crohn disease, a non-healing, transmural ulcer present in the anal canal can progress to form a rectovaginal fistula.
In addition to standard Crohn disease management like anti-TNF inhibitors, glucocorticoids, etc patients with a rectovaginal fistula may require surgical correction.

Bartholin gland cysts or abscesses can present with malodorous vaginal discharge; however, patients typically have a posterior vulvar mass located at the 4 or 8 o’clock position. In addition, Bartholin gland cysts will not present with crampy abdominal pain or passage of flatus or stool through the vagina.

Hidradenitis which is the chronic occlusion and inflammation of hair follicles, can cause groin abscesses with sinus tracts and associated purulent drainage.  However, it is not associated with abdominal pain or malodorous vaginal discharge. In addition, this condition is typically multifocal and located in more than one intertriginous areas like axillary, inguinal or gluteal regions.

Cervical cancer or a retained foreign body in the vagina can cause malodorous vaginal discharge and abdominal pain.  However, patients will typically have visible findings like cervical lesion, foreign body etc on speculum examination, and these neither are associated with the passage of flatus through the vagina.

Complications of Crohn disease include perianal disease like abscess, fissure and fistula like rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract.  Patients with a rectovaginal fistula typically presents with malodorous, tan vaginal discharge, passage of flatus through the vagina and a posterior vaginal lesion.

OCPs which contain oestrogen and progesterone are contraindicated in women who have migraines associated with a neurological deficit or aura (pins and needles in this case). In such cases, the alternative would be Implanon (etonogestrel), however, there are mixed reviews and opinions regarding whether or not there is a decreased efficacy in heavier women. The absolute contraindication for Implanon is active breast cancer. Therefore, the best advice for her case would be some form of barrier contraceptive.

When choosing a COCP (combined oral contraceptive pill), it is recommended that a formulation containing 20-30ug of ethinyl oestradiol is chosen. The progestogen part is responsible for prevention of conception and can be norgestrel or any other progestogens although the formulations containing norgestrel tend to be cheaper than more novel progestins such as cyproterone acetate as well as drospirenone. If the patient is known to have issues with excessive fluid retention, OCPs that has drospirenone would be the most suitable. However, if the patient is suspected to have PCOS, the best choice would be one that contains cyproterone acetate.

G0 is a resting phase. Interphase (G1,S,G2) is where the cell grows and DNA replication occurs forming chromatids. Mitosis is where cell division occurs and this happens in a the following phases: Prophase Chromatin condenses to chromosomes (paired as chromatids). Mitotic spindle forms Metaphase Chromatids align at the equatorial plane AKA the metaphase plate Anaphase Chromatids pulled apart into 2 constituent daughter chromosomes Telophase New nuclear envelopes form around each daughter chromosome Cytokinesis Cells divide Diagram illustrating Mitosis Image sourced from Wikipedia

Standard karyotyping is the best confirmatory test for the diagnosis of Turner syndrome among patients who have some doubtful clinical presentations. It is done on peripheral blood mononuclear cells.

Testing for GD should use the 2 hour 75g oral glucose tolerance test (OGTT) to test for GD in women. Testing women who have had GD in a previous pregnancy: early self monitoring of blood glucose OR a 75 g 2 hour OGTT as soon as possible after booking (whether in the first or second trimester) and a further 75 g 2hour OGTT at 24-28 weeks if the results of the first OGTT are normal. Testing women with risk factors for GD: 75g 2 hour OGTT at 24-28 weeks

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.

Basophils are granulocytic white blood cells. They express IgE antibody on their surface and react to release prostaglandins and leukotrienes to mediate an inflammatory, allergic reaction.
Blood Cell Lifespans:
Red Blood Cells 120 days
Platelets 5-9 days
White blood cells 2-5 days

Neutrophils (up to 5 days)
Basophils (2 to 3 days)
Eosinophils (2 to 5 days)
Monocytes (1 to 5 days)
Lymphocytes (variable)

Free T3 (FT3) and free T4 (FT4) levels are slightly lower in the second and third trimesters. Thyroid-stimulating hormone (TSH) levels are low-normal in the first trimester, with normalization by the second trimester.

This patient has experienced polycystic ovarian syndrome-like symptoms.
At least two out of three of the following criteria must be met to diagnose polycystic ovarian syndrome:
1- Hyperandrogenism suggesting an excess of androgens e.g. excess hair growth, acne etc.
2- Menstrual irregularities e.g. dysmenorrhea, oligomenorrhea, and amenorrhea.
3-The ovaries are polycystic if one ovary has 12 or more follicles or if the size of one or both ovaries has risen.

Low FSH, LH, and pituitary hormones are typically associated with hypothalamic dysfunction, however this is not the case here.
Similarly, with premature ovarian failure, FSH/LH levels rise while oestrogen levels decrease.

All of the other choices are incorrect.

Arcuate means ‘bow shaped’ and there are different arcuate lines in anatomical terms. Regarding the pelvic brim this is composed of the arcuate line of the ilium, pectineal line and prominences of sacrum and pubic symphysis (as demonstrated in the images below). As can be seen the arcuate line is a smooth rounded border on the internal surface of the ilium inferior to the iliac fossa and Iliacus. Image sourced from Wikipedia Note: The pelvic outlet is also called the inferior aperture. The pelvic brim is the superior aperture

Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis – Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis. This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage- Because the patient’s HBsAg is negative, she is not the source of her husband’s infection. Full treatment for this patient has an efficacy of only 75%, so follow-up testing is still needed.

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.

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

Transportation of the maternal IgG through the placenta starts around the 12 week of gestation.

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

Around 30-40% of women affected by this condition complain of difficulty in conceiving.

The partial mole is produced when an egg is fertilized by two sperm producing genotype 69 XXY (triploid). It can also occur when one sperm reduplicates itself yielding the genotypes 92 XXXY (tetraploid) though this is less common The genotype of a complete mole is typically 46 XX (diploid) but can also be 46 XY (diploid)

Prelabour Rupture of Membranes:
– Risk of serious neonatal infection 1% (vs 0.5% for women with intact membranes)
– 60% of patients with PROM will go into labour within 24 hrs
– Induction appropriate if >34 weeks gestation and >24 hours post rupture and patients labour hasn’t started.
– If <34 weeks induction of labour should not be carried out unless there are additional obstetric indications e.g. infection

Ergot alkaloids e.g. Ergometrine, produce marked and prolonged alpha receptor mediated vasoconstriction. Its overdose can cause ischemia and gangrene of the limbs and bowel. It also causes coronary artery spasm and has been used by cardiologist as a provocation test.

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).

A screening blood test for the infectious diseases HIV, Syphilis, Rubella, Toxoplasmosis and Hepatitis B is offered to all pregnant females so as to reduce the chances of transmission to the neonate.

Dehydroepiandrosterone is an androgen precursor produced primarily by the adrenal glands in women. The steroid hormone is produced from cholesterol at birth by the fetal adrenal glands, after which its output reduces. DHEA production picks up again from the age of 5-7 years and peaks between the ages of 20-30.

Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.

This patient presents with secondary amenorrhea, most likely caused by Asherman’s syndrome- Secondary amenorrhea is defined as absence of menstruation for – 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea- Asherman’s syndrome as the cause of her amenorrhea is suggested by its beginning shortly after undergoing elective abortion. It is an outflow tract obstruction caused by intrauterine synechiae resulting from the procedure.

The best diagnostic test to confirm this diagnosis is hysteroscopy. It can allow visualization of the uterine cavity, the nature and extent of intrauterine synechiae.

→ Progesterone withdrawal test is one of the diagnostic studies done in the early work-up of secondary amenorrhoea- It is usually followed by the estrogen-progesterone challenge test and other tests. Progesterone withdrawal test alone would not confirm Asherman’s syndrome.
→ Pelvic ultrasound is more useful in primary amenorrhea work-up when the presence or absence of the uterus is to be confirmed- It is not very useful in the evaluation of intrauterine adhesions.
→ Brain MRI is useful in confirming the presence of pituitary tumours in patients, who are found to have high levels of prolactin. This patient’s most likely cause of secondary amenorrhea is Asherman’s syndrome.
→ TSH and prolactin levels should be the next step in the work-up of secondary amenorrhea after pregnancy has been ruled out; however, these studies cannot confirm Asherman’s syndrome.

Mitral stenosis is the most common cardiac condition affecting women during pregnancy and is poorly tolerated due to the increased intravascular volume, cardiac output and resting heart rate that predictably occur during pregnancy.

Young women may have asymptomatic mitral valve disease which becomes unmasked during the haemodynamic stress of pregnancy. Rheumatic mitral stenosis is the most common cardiac disease found in women during pregnancy. The typical increased volume and heart rate of pregnancy are not well tolerated in patients with more than mild stenosis. Maternal complications of atrial fibrillation and congestive heart failure can occur, and are increased in patients with poor functional class and severe pulmonary artery hypertension.

Nipple stimulation during breastfeeding triggers the production of oxytocin from the hypothalamus and its subsequent release from the posterior pituitary gland. The hormone causes the myoepithelial cells of the breast to contract causing milk to flow through the ducts.

Ergometrine and Prostaglandin E2 are used during labour to control uterine bleeding after delivery, or ripen the cervix, while Atosiban is an oxytocin antagonist.

Antidiuretic hormone is also released from the posterior pituitary, and acts on the kidneys to decrease fluid excretion.

Adnexa refer to the anatomical area adjacent to the uterus, and contains the fallopian tube, ovary, and associated vessels, ligaments, and connective tissue. The reported incidence of adnexal masses in pregnancy ranges from 1 in 81 to 1 in 8000 pregnancies. Most of these adnexal masses are diagnosed incidentally at the time of dating or first trimester screening ultrasound (USS). Functional cyst is the most common adnexal mass in pregnancy, similar to the nonpregnant state. A corpus luteum persisting into the second trimester accounts for 13-17% of all cystic adnexal masses. Pain due to rupture, haemorrhage into the cyst, infection, venous congestion, or torsion may be of sudden onset or of a more chronic nature.

Women who have used oral contraceptives for 5 years or more are more likely to get cervical cancer than women who have never used them. The longer a woman uses oral contraceptives, the higher her chances of developing cervical cancer become. According to one study, using marijuana for less than 5 years increases the risk by 10%, using it for 5–9 years increases the risk by 60%, and using it for 10 years or more increases the risk by double. After women cease using oral contraceptives, their risk of cervical cancer appears to decrease over time. Endometrial, ovarian, and colorectal cancer risks, on the other hand, are lowered.
Compared to women who had never used oral contraceptives, women who were taking or had just discontinued using oral combination hormone contraceptives had a slight (approximately 20%) increase in the relative risk of breast cancer. Depending on the type of oral combination hormone contraception used, the risk increased anywhere from 0% to 60%. The longer oral contraceptives were used, the higher the risk of breast cancer.