Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.

The factor associated with the greatest relative risk for endometrial carcinoma is polycystic ovary syndrome, which has a relative risk of 75. The use of long-term high doses of postmenopausal oestrogen carries an estimated risk of 10-20. Living in North America or Europe also has an estimated risk of 10-20.

A lower relative risk is associated with nulliparity, obesity, infertility, late menopause, older age, and white race- The relative risk associated with these factors falls into the range of 2-5. Early menarche, higher education or income levels, menstrual irregularities, and a history of diabetes, hypertension, gall bladder disease, or thyroid disease have a relative risk of around 1.5-2.0.

The incidence of monozygotic twins is constant worldwide (approximately 4 per 1000 births). Approximately two thirds of twins are dizygotic.

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

No adverse reactions in breastfed infants have been reported from maternal warfarin use during lactation, even with a dose of 25 mg daily for 7 days. There is a consensus that maternal warfarin therapy during breastfeeding poses little risk to the breastfed infant.

PKD can follow either Autosomal dominant or recessive inheritance. Autosomal dominant is however the most common inheritance pattern and is seen in adult PKD. Infantile PKD is recessive

If the external anal sphincter is in tact then this is a 1st or 2nd degree tear. As the perineal muscles are involved this is 2nd degree tear.

Congenital infections can be the cause of various congenital abnormalities. Infection with the Rubella virus, part of the TORCH infections (toxoplasmosis, other organisms, rubella, cytomegalovirus, and herpes simplex), can lead to cardiac abnormalities, ophthalmic defects, sensorineural deafness and neurodevelopmental delays. At birth congenital rubella syndrome presents with a petechial rash characteristically dubbed a blueberry muffin rash, and hepatosplenomegaly with jaundice. Immunization of the mother against measles is an effective way of reducing the occurrence of congenital rubella syndrome.

Adenomyosis or dysfunctional uterine haemorrhage are the most likely causes of heavy periods.
Because she refuses to have a hysterectomy or endometrial ablation, hormonal therapy must be administered in addition to the iron therapy she is already receiving.
Any of the choices could be employed, but using therapy only during the luteal phase of the cycle in someone who is virtually surely ovulating (based on her typical monthly cycles) is unlikely to work.

Danazol is prone to cause serious adverse effects (virilization), especially when used for a long period of time.
GnRH agonists would cause amenorrhoea but are more likely to cause substantial menopausal symptoms, and the °fa contraceptive pill (OCP) is generally best avoided in someone using hypertension medication.

Treatment with norethisterone throughout the cycle is likely to be the most successful of the treatments available.
If a levonorgestrel-releasing intrauterine device (Mirena®) had been offered as an alternative, it would have been acceptable.

There are many different reasons for performing a delivery by Caesarean section. The four major indications accounting for greater than 70 per cent of operations are: 1. previous Caesarean section 2. dystocia 3. malpresentation 4. suspected acute fetal compromise. Other indications, such as multifetal pregnancy, abruptio placenta, placenta praevia, fetal disease and maternal disease are less common. The chances of early postpartum haemorrhage are greatly reduced in C-section deliveries.

The vaginal epithelium is made of squamous cells. Hence the most common carcinoma that occurs in the Vagina is squamous cell carcinoma. Diagnosis is made with vaginal biopsy. Usually the pain only presents if the disease extends beyond the vagina involving the perineal nerves.

Tamoxifen and Raloxifene are drugs which acts as selective estrogen receptor modulators.
Their mechanisms of action are competitive inhibitor of estrogen binding and mixed agonist/antagonist action respectively.
Commonly indicated in prevention of breast cancer in high-risk patients. Tamoxifen as adjuvant treatment of breast cancer and Raloxifene in postmenopausal osteoporosis.
Adverse effects include:
– Hot flashes
– Venous thromboembolism
– Endometrial hyperplasia & carcinoma (tamoxifen only)
– Uterine sarcoma (tamoxifen only)
Adjuvant endocrine therapy is commonly used option for treatment of nonmetastatic, hormone-receptor-positive breast cancer; and the most commonly used endocrine agents include tamoxifen, aromatase inhibitors, and ovarian suppression via GnRH agonists or surgery.

Tamoxifen is a selective estrogen receptor modulator which is an estrogen receptor antagonist in the breast.  It is the most preferred adjuvant treatment for pre-menopausal women at low risk of breast cancer recurrence.  Tamoxifen is also a second-line endocrine adjuvant agent for postmenopausal women who cannot use aromatase inhibitor therapy due to intolerable side effects.
Tamoxifen acts as an estrogen agonist in the uterus and stimulates excessive proliferation of endometrium. Therefore, tamoxifen use is associated with endometrial polyps in premenopausal women, and endometrial hyperplasia and cancer in postmenopausal women. These effects will continue throughout the duration of therapy and resolves once the treatment is discontinued. Even with all these possible complications, benefits of tamoxifen to improve the survival from breast cancer outweighs the risk of endometrial cancer.

In postmenopausal women, tamoxifen has some estrogen-like activity on the bone, which can increase bone mineral density and thereby reduce the incidence of osteoporosis significantly.  However, tamoxifen is generally not a first-line agent for osteoporosis in treatment due to the marked risk of endometrial cancer.

Dysplasia of the cervical transformation zone is typically caused due to chronic infection by human papillomavirus, and tamoxifen has no known effects on the cervix.

Tamoxifen is not associated with any increased risk for adenomyosis, which is characterised by ectopic endometrial tissue in the myometrium.

Intimal thickening of the coronary arteries is a precursor lesion for atherosclerosis. Tamoxifen helps to decrease blood cholesterol level and thereby protect against coronary artery disease.

Tamoxifen is an estrogen antagonist on breast tissue and is used in the treatment and prevention of breast cancer, but it also acts as an estrogen agonist in the uterus and increases the risk of development of endometrial polyps, hyperplasia, and cancer.

The commonest foetal presentation in twin pregnancy is cephalic-cephalic.

The tests listed can all be performed during the work-up of a woman with secondary amenorrhoea. They are useful in that they cam diagnosis the most likely cause for the amenorrhoea as well as guide the treatment required if the patient wanted to become pregnant. Of these, the hormone test best able to predict a poor response to ovulation-induction therapy is the follicle-stimulating hormone (FSH) assay. If there are high levels of FSH, most of the ovulation-induction therapies are ineffective, although the rare spontaneous pregnancy can occur.

To maximise the chance of pregnancy in patients with elevated FSH levels, the most effective technique is an ovum donation from a young woman. The ovum would be fertilised in the laboratory and transferred to the uterus of the woman with the high FSH level after administering hormonal preparation of her uterus.

If the FSH level is normal, ovulation-induction therapy is usually effective. For these patients, correction of thyroid function will be necessary if the thyroid function is not normal. Dopamine agonist therapy is indicated if the prolactin level is elevated. Clomiphene or gonadotrophin therapy can be used where the luteinising and oestradiol levels are low, normal, or minimally elevated.

An LSIL Pap test shows mild cellular changes. The risk of a high-grade cervical precancer or cancer after an LSIL Pap test is as high as 19 percent.

As with an ASC-US Pap test, an LSIL Pap test is evaluated differently depending upon age. For women ages 25 or older, follow-up depends upon the results of human papillomavirus (HPV) testing:

– Women who test positive for HPV or who have not been tested for HPV should have colposcopy.
– Women who test negative for HPV can be followed up with a Pap test and HPV test in one year.

All other options are not acceptable for the above mentioned reasons.

P wave = Atrial depolarisation
QRS complex = Ventricular depolarisation
T wave = Ventricular repolarisation
U wave = repolarisation of the interventricular septum

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

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.

Rhesus positive mothers should not get anti-D. They have Rhesus antigens and the anti-D would result in maternal blood being bound and removed from her circulation. The danger is to children born to mothers who are rhesus negative. As the mother may develop antibodies against Rhesus positive fetal blood. Therefore if the baby is Rhesus negative then there is no risk of alloimmunisation (sensitisation)

The arcuate line is a smooth rounded border on the internal surface of the ilium just inferior to the iliac fossa. It forms the boundary of the pelvic inlet.

Endometrioid endometrial carcinoma is oestrogen-responsive, and the main risk factor for this disease is long-term exposure to excess endogenous or exogenous oestrogen without adequate opposition by a progestin.

Early age at menarche is a risk factor for endometrial carcinoma in some studies; late menopause is less consistently associated with an increased risk of the disease. Both of these factors result in prolonged oestrogen stimulation and at times of the reproductive years during which anovulatory cycles are common

Other risk factors include
obesity,
nulliparity,
diabetes mellitus, and
hypertension.

The risk of endometrial hyperplasia and carcinoma with oestrogen therapy can be significantly reduced by the concomitant administration of a progestin. In general, combined oestrogen-progestin preparations do not increase the risk of endometrial hyperplasia.

Endometrial carcinoma usually occurs in postmenopausal women (mean age at diagnosis is 62 years). Women under age 50 who develop endometrial cancer often have risk factors such as obesity or chronic anovulation.

Ladd’s bands are the most common form of peritoneal bands in malrotation of the intestine.

The changes seen in breast tissue with the menstrual cycle are accentuated during pregnancy. Deposition of fat around glandular tissue occurs, and the number of glandular ducts is increased by oestrogen, while progesterone and human placental lactogen (hPL) increase the number of gland alveoli. Prolactin is essential for the stimulation of milk secretion and during pregnancy prepares the alveoli for milk production. Although prolactin concentration increases throughout pregnancy, it does not then result in lactation since it is antagonized at an alveolar receptor level by oestrogen.

When cervical biopsy or colposcopy doesn’t explain the severity of the pap smear results cone biopsy is done. In 10% of biopsies, results will be different from that of the pap smear as in this patient with pap smear showing HSIL and colposcopy showing chronic cervicitis.

In such cases conization is indicated. Repeating the pap smear could risk prompt management of a serious problem. No destructive procedure, ablation or cryotherapy, should be done before diagnosis is certain.

Progestin only pills increase the risk of developing follicular cysts. Sonographic studies have observed that follicular cysts are more common in POP users than women not using hormones. The follicular changes tend to increase and regress over time. No intervention is required in asymptomatic women, other than reassurance. POP users who have persistent concerns about ovarian follicular changes should be offered another method of contraception.

All other options are not contraindications to the use of mini-pills.

T-Helper cells type 2 increase during pregnancy. They secret cytokines IL-4,5,9,10 and 13.

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.

The most consistent finding in obstructed labour is a 4cm head that is palpable in 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).

Predisposing factors of preterm delivery include a short cervix (or if it shortens earlier than in the third trimester), urinary tract or sexually transmitted infections, open cervical os, and history of a previous premature delivery. Increased uterine size can also contribute to preterm delivery and is seen with cases of polyhydramnios, macrosomia and multiple pregnancies. The shorter the cervical length, the greater the risk of a premature birth.
In this case, the risk of bacterial vaginosis and candidiasis contributing to preterm delivery would be lower than if in the context of an open cervical os. However, the risk of premature delivery is significantly increased if it is found that the fetal fibronectin test is positive, even if the os is closed.

First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour in a British journal was having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.

Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.

Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.