The correct answer is reassurance after thorough examination. Most breast lesions diagnosed during pregnancy and lactation, even some specific ones such as lactation and adenoma galactocele, are benign. The diagnosis of breast cancer, which is difficult to elucidate and is less common among women who are pregnant or lactating than among those of the same age who are not, continues to be a challenge for clinicians.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. There are various risk factors for gestational diabetes including increasing age, ethnicity, previous still births etc.

The best next step is to order an ultrasound of the pelvis to locate the IUCD in the uterine cavity.

Once the device is located, appropriate advice can be given about the pregnancy proceeding.

Uterine sounding and hysteroscopy are contraindicated in the presence of a viable pregnancy due to risks of infection and abortion.

Pelvic X-ray is indicated if the device cannot be located during the pelvic ultrasound. It can show if the device is in the peritoneal cavity or has been expelled from the uterus. It should only be done after the pregnancy.

In cases where the device is in the peritoneal cavity, a laparoscopy is indicated for device removal.

Pregnancy termination is not indicated simply because of the presence of an intrauterine device (IUCD) in the uterus, unless other factors dictate that this is appropriate.

Intrahepatic cholestasis characterized by reversible cholestasis typically occurring in the second or third trimester of pregnancy, elevated serum aminotransferases and bile acid level and resolution of symptoms by 2 to 3 weeks after delivery. Ursodeoxycholic acid has shown to reduce the symptoms of this condition.

The best next step in management would be to remove the cervical ectropion using cautery. This would usually be performed under anaesthesia. It can take up to a month to heal following the procedure. Vaginal pessaries and antibiotics are typically not effective.

Indications for a cone biopsy include an abnormal pap smear, lesion suspected to be a CIN on colposcopic examination that cannot be fully visualised as well if there is a histological discrepancy between the smear and biopsy. Colposcopic examination is also unnecessary at this stage since she has not complained of any abnormal per vaginal bleed nor is her last pap smear abnormal.

Since the discharge is now affecting the patient’s life, treatment should be given so reassuring her that no treatment is needed is not appropriate.

Testing for beta hCG should be the first test in this case. It will rule out any pregnancy that is strongly suspected based on the patient’s history and physical examination.

Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. It can be a sign of serious underlying pathology and is usually alarming for patients. About one-third of patients also have abnormal uterine bleeding that is not associated with coitus and about 15 percent have dyspareunia. The most serious cause of postcoital bleeding is cervical cancer. About 11 percent of women with cervical cancer present with postcoital bleeding. The patient should undergo cervical cancer screening according to local guidelines. Postcoital bleeding is not an indication for cervical cytology if previous screening tests are up-to-date and normal.

Cervical screening and liquid based cytology are superior to transvaginal ultrasound.

Coagulation profile can be done if cytology is normal to rule out bleeding diathesis.

Tranexamic acid can be considered once malignancy is ruled out and cause of bleeding has been established.

This lady is most likely suffering from primary syphilis. Since the chancre is asymptomatic, it is often only found on deep examination of the vulvo-vaginal mucosa. The chief organism causing syphilis is Treponema Pallidum which is a spirochete and one of the most widely distributed sexually transmitted infections.

Fetal production of immunoglobulin begins early on at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth, through breast milk.

The internal anal sphincter is innervated by the splanchnic nerves. Sympathetic nerve supply from the inferior hypogastric plexus (for contraction) and parasympathetic supply from nervi erigentes (for relaxation).

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justified to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specificity for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. The women should be tested as soon as possible after booking if there is a history of GD.

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.

Chickenpox or varicella is a contagious disease caused by the varicella-zoster virus (VZV). The virus is responsible for chickenpox (usually primary infection in non-immune hosts) and herpes zoster or shingles (following reactivation of latent infection). Chickenpox results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the chest, back, and face then spreads. It is accompanied by fever, fatigue, pharyngitis, and headaches which usually last five to seven days. Complications include pneumonia, brain inflammation, and bacterial skin infections. The disease is more severe in adults than in children.

Primary varicella infection during pregnancy can also affect the foetus, who may present later with chickenpox. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the foetus. Varicella infection in pregnant women could spread via the placenta and infect the foetus. If infection occurs during the first 28 weeks of pregnancy, congenital varicella syndrome may develop. Effects on the foetus can include underdeveloped toes and fingers, structural eye damage, neurological disorder, and anal and bladder malformation.

Prenatal diagnosis of fetal varicella can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised.

Antivirals are typically indicated in adults, including pregnant women because this group is more prone to complications.

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.

Literature review shows that bicornuate uterus is associated with increase risk of spontaneous abortion in about 36% of patients. There is also an increased risk of preterm birth, malpresentation and fetal growth retardation.

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

Chlamydia is one of the most prevalent STIs in the UK. Many infected individuals can be asymptomatic making it difficult to detect. The gold standard in the diagnosis of Chlamydia is the nucleic acid amplification test (NAAT). A sample is taken from a vulvovaginal self swab, or a cervical swab on speculum examination in women.

Menorrhagia in a 45-year-old woman is most likely caused by an ovulation issue, most likely anovulatory cycles, particularly if the periods have grown irregular.

Endometrial carcinoma is a rare cause of menorrhagia that usually occurs after menopause.

Menorrhagia can be caused by fibroids, endometrial polyps, and adenomyosis, although the cycles are normally regular, and a dramatic change from normal cycles six months prior would be exceptional.
If fibroids or adenomyosis are the source of the menorrhagia, the uterus is usually enlarged.

Repair the vaginal mucosa using rapidly absorbed suture material on a large, round body needle. Start above the apex of the cut or tear (as severed vessels retract slightly) and use a continuous stitch to close the vaginal mucosa.

The half life of oxytocin is 5 mins, which is why is should be started as an infusion at a low rate.

Premature menopause is most commonly idiopathic.

Hepatitis B is a DNA virus. All the others are RNA viruses

Ventilation begins to increase significantly at around 8 weeks of gestation, most likely in response to progesterone-related sensitization of the respiratory centre to carbon dioxide and the increased metabolic rate. Significant alterations occur in the mechanical aspects of ventilation during pregnancy. Minute ventilation (or the amount of air moved in and out of the lungs in 1 minute) is the product of tidal volume and respiratory rate and increases by approximately 30–50 per cent with pregnancy. The increase is primarily a result of tidal volume, which increases by 40 per cent (from 500 to 700 mL), because the respiratory rate remains unchanged. The increase in minute ventilation is perceived by the pregnant woman as shortness of breath, which affects 60–70 per cent of women. This physiological dyspnoea is usually mild and affects 50 per cent of women before 20 weeks gestation, but resolves immediately postpartum.

Face presentation is the abnormal position of the fetal head in labour. In this position the neck is hyperextended.
Vertex position is the normal presentation of the foetus for delivery, in which the head is flexed and the position of the chin is towards the chest.

A pH value below than 7.18 indicates acidosis which can result in hypoxic brain injury. In order to prevent brain injury, immediate delivery of the foetus should be planned. The normal range for a term baby is pH: 7.18 – 7.38, preterm pH: 7.14 – 7.4.

The incubation period of varicella is 10-21 days.

Patient mentioned above is a known case of type 2 diabetes which makes her at high risk of having neural tube defects. She should be advised to start taking a high dose of (5mg) folic acid supplement daily for at least 1-month prior to conception and it should be continued upto 12 weeks of her pregnancy.

Folate, which is a water-soluble B vitamin, is usually obtained from diet or through supplementation. For those patients with a history of type 2 diabetes mellitus, who are planning for pregnancy, high doses are recommended to prevent any possible neural tube defects.

Vitamin A is not safe and should be avoided in pregnancy due to chances for toxicity.

Vitamin C and iron are not considered as essential vitamins to be taken during pregnancy.

IUS or Intra Uterine System/Device releases progestin. The progestin thickens the cervix, preventing the sperm from penetrating the cervix, and it also causes the uterine lining to become thinner, preventing any implantation. IUS may also prevent excessive bleeding and can help women with fibroids.

Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.

The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.

The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.

As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.

Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.

Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.

Serum progesterone has been proposed as a useful test to distinguish a viable pregnancy from a miscarriage or ectopic pregnancy. Low progesterone values are associated with miscarriages and ectopic pregnancies, both considered non-viable pregnancies, and high progesterone concentrations with viable pregnancies. A single progesterone measurement for women in early pregnancy presenting with bleeding or pain and inconclusive ultrasound assessments can rule out a viable pregnancy. The probability of a non-viable pregnancy was raised from 62.9% to 96.8%.