This lady should be admitted to hospital for early surgical exploration. Taking into account her age, mild abdominal discomfort and a palpable lower abdominal mass, it is imperative that ovarian malignancy be ruled out as soon as possible. Patients with ovarian malignancy often present in advanced stages of cancer as the symptoms tend to be occult and non-specific. Other things to include in her workup would be her CA125 level. Any form of hormonal therapy is contraindicated until ovarian malignancy has been ruled out. A pap smear is not relevant here since we are suspecting an ovarian malignancy rather than cervical. Evaluation of her mass takes priority over an assessment for osteoporosis.

Tetracycline is classified as a broad spectrum antibiotic. It is a bacteriostatic inhibitor of protein synthesis acting at the ribosomal level. Tetracycline binds to the 30s ribosomal subunit preventing the binding of the aminoacidic charged T-RNA to the ribosome-mRNA complex.

Eisenmenger’s syndrome is one where there is communication between the systemic and pulmonary system, along with increased pulmonary vascular resistance, either to systemic level or above systemic level (right to left shunt). A would-be mother must be informed that to become pregnant would incur a 50% risk of dying. Even if she survives, fetal mortality approaches 50% as well.

– Severe symptomatic aortic stenosis has a mortality in pregnancy of about 20%. Prevention of reduction in preload is necessary in all obstructive cardiac lesions. Balloon valvuloplasty can be done in pregnancy.
– Due to the increased blood volume and cardiac output in pregnancy, mitral stenosis can lead to severe pulmonary oedema. Balloon valvuloplasty can be done in pregnancy.
– Ebstein anomaly is a malformation of the tricuspid valve- It is usually not associated with maternal mortality.
– Atrial-septal defects rarely cause complications in pregnancy, labour, or delivery.

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)

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.

At 12 weeks gestation the fundus is expected to be palpable above the pubis symphysis and it is expected to be felt at the level of umbilicus by 20 weeks. Though the uterine fundus stands in between from 12 and 20 weeks, the height of the fundus in centimeters is equivalent to the weeks of pregnancy after 20 weeks.

For 14-week pregnant uterus a fundal height of 18cm is definitely large and dating errors is considered as the most common cause for such a discrepancy. Hence, it is better to perform an ultrasound scan for more accurately estimating the gestational age. Also if the case is not a simple dating error, ultrasonography can provide definitive additional information about other possible conditions such as polyhydramnios, multiple gestation, etc that might have led to a large-for-date uterus.

A large-for-gestational-age uterus are most commonly found in conditions like:
– Dating errors which is the most common cause
– Twin pregnancy
– Gestational diabetes
– Polyhydramnios
– Gestational trophoblastic disease, also known as molar pregnancy

The contents of the femoral triangles are femoral nerve, artery and the vein. Along with the femoral sheath and lymphatics.

Bacterial vaginosis (BV) is a clinical condition characterized by a shift in vaginal flora away from Lactobacillus species toward more diverse bacterial species, including facultative anaerobes. The altered microbiome causes a rise in vaginal pH and symptoms that range from none to very bothersome. Future health implications of BV include, but are not limited to, increased susceptibility to other sexually transmitted infections and preterm birth. Fifty to 75 percent of women with BV are asymptomatic. Symptomatic women typically present with vaginal discharge and/or vaginal odour. The discharge is off-white, thin, and homogeneous; the odour is an unpleasant fishy smell that may be more noticeable after sexual intercourse and during menses.

Even if conception has already occurred, beta hCG is likely to be normal. Beta hCG is made by syncytiotrophoblast cells following conception. It then activates the corpus luteum to continuously produce progesterone for implantation to happen. In week 10/40, levels of HCG peak and the placenta can produce adequate progesterone by itself. As a general rule, a beta HCG concentration >25 U/I or a doubling of levels of HCG within two days is required to diagnose pregnancy. A urine pregnancy test would only likely prove positive around 8 days to 2 weeks following conception.

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

To help protect babies during this time when they are most vulnerable, women should get the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.

Pregnant women should receive Tdap anytime during pregnancy if it is indicated for wound care or during a community pertussis outbreak.
If Tdap is administered earlier in pregnancy, it should not be repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.

Optimal timing is between 27 and 36 weeks gestation (preferably during the earlier part of this period) to maximize the maternal antibody response and passive antibody transfer to the infant.
Fewer babies will be hospitalized for and die from pertussis when Tdap is given during pregnancy rather than during the postpartum period.

Prostaglandins are involved in the uterine contraction and cervical dilatation during labour. Higher prostaglandin concentrations can also lead to severe menstrual cramps.

In hyperemesis gravidarum, IV corticosteroids can be given to reduce vomiting, if the patient is not responding to standard anti emetics.

Gonorrhoea is a sexually transmitted disease that is caused by Neisseria gonorrhoea. It infects the mucous membrane of the genital tract epithelium in the endocervical and the urethral mucosa. Around 50% of the women are asymptomatic. However it presents as increase vaginal discharge, dysuria, proctitis and pelvic tenderness.

1st Arch = Trigeminal V2 & V3 (CN V) 2nd Arch = Facial (CN VII) 3rd Arch = Glossopharyngeal (CN IX) 4th and 6th Arches = Vagus (CN X)

Mirena is a form of contraception also indicated for the treatment of heavy menstrual bleeding and the management of dysmenorrhea, being able to reduce the latter considerably.

There is an increase risk of developing carcinoma of the uterus, if the endometrium shows hyperplasia with atypia. The standard surgery is total hysterectomy with bilateral salpingectomy which can be performed abdominally or laparoscopically If the disease is grade 1-2 and less than 1B i.e. less than 50% invasion of the uterine body.

Tubal sterilization is a safe and effective surgical procedure that permanently prevents pregnancy. However, pregnancy can occur in 1 in 200 cases, according to international sources. In the 1st year after tubal sterilization, the estimated failure rate is 0.1-0.8% respectively.

Breakthrough bleeding, or spotting, refers to when vaginal bleeding occurs between menstrual cycles. It may look like light bleeding or brown discharge.

Spotting is the most common side effect of birth control pills. It happens because the body is adjusting to changing levels of hormones, and the uterus is adjusting to having a thinner lining.

Taking the pill as prescribed, usually every day and at the same time each day, can help prevent bleeding between periods.

All other options are incorrect as this is a common side effect and will resolve on its own.

Progesterone down regulates gastric motility meaning drugs are absorbed and metabolised more slowly, thus drugs are absorbed, metabolised and cleared more slowly. Most of the drugs are transported after binding to the albumin.
Lower albumin levels mean a greater unbound drug fraction but as this may be thought to increase drug concentrations it actually leaves more available for hepatic clearance or renal excretion so overall drug concentrations are unchanged and metabolism increased.
Increase in hepatic flow will increase the metabolism of the drug as the drug will be transported faster.
Increased renal blood flow will result in the faster clearance of the drug from the body.

Androgen insensitivity syndrome patients have 46XY chromosomes. They are males by genotype but appear as female because of insensitivity to male hormones. It is advisable to perform gonadectomy in these patients after puberty because these patients are at increased risk of developing malignancy.

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.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

It is stage 2B. Stage I: is strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion.
2010 FIGO classification of cervical carcinoma:
Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.

Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
Stage IB1: Clinical lesions no greater than 4 cm in size.
Stage IB2: Clinical lesions greater than 4 cm in size.

Stage II: carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall.

Stage III: carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.

Stage IV: carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.
Stage IVA: Spread of the tumour into adjacent pelvic organs.
Stage IVB: Spread to distant organs.

Ovulation usually occurs on day 14 in a typical 28-day cycle. Luteinizing hormone levels spike as a result of increased oestrogen levels secreted from maturing follicles. This LH spike occurs about 24-36 hours before the release of the oocyte from the mature follicle.

In women of childbearing age, the most likely cause of abnormal vaginal bleeding is pregnancy; thus, the most appropriate initial test would be an hCG level. Once pregnancy has been excluded, patient history would guide further testing. Iatrogenic causes, usually resulting from certain medicines or supplements, are the next most common cause in this age group, followed by systemic disorders. Haemoglobin and haematocrit would be appropriate only if the patient seemed acutely anaemic due to the abnormal bleeding.

Fat necrosis may occur following a traumatic injury to the breast. The lump is usually firm, round, and painless.

This patients bloods and symptoms suggest she has hepatic impairment. Acute fatty liver of pregnancy typically presents after the 30th week and she has risk factors for acute fatty liver of pregnancy: Multiple pregnancy Primigravida

In a person who is infected by streptococcus (Group B) should be started on benzylpenicillin as soon as possible. In case of allergy vancomycin should be started at 1g every 12 hours. Tetracyclines should be avoided in pregnancy.

Fetal nutrition is dependant upon multiple factors such as maternal nutritional state, quality of maternal diet, malnutrition, anorexia nervosa, metabolic rate of the mother or whether they suffer from malabsorption syndrome or other related conditions.