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)

Lamotrigine, a drug used to treat epilepsy, is less effective when taken with combined oral contraceptives. The oestrogen component of the pill decreases the circulating levels of Lamotrigine, increasing the risk of seizures. The combination is therefore classified as a UKMEC 3, as the risk of the drug combination may outweigh the benefit. As an alternative, the progesterone-only pill, depo progesterone, Mirena or the copper IUD may be considered as there is no restriction on concomitant use. Lamotrigine is not metabolised through cytochrome P450 like other antiepileptic drugs such as carbamazepine and phenytoin, neither is it an enzyme inhibitor.

Factor V Leiden is the most common congenital thrombophilia. Named after the Dutch city Leiden where it was first discovered. Protein C and S deficiencies are type 1 (Not type 2) thrombophilias Antiphospholipid syndrome is an acquired (NOT congenital) thrombophilia

The incubation period of varicella is 10-21 days.

Skin signs during pregnancy may include: dark spots on the breasts, nipples and inner thighs, melasma (chloasma), linea nigra, stretch marks, acne, spider telangiectasis and varicose veins.

Activation of Antithrombin III and inactivation of factor Xa is the primary mechanism of action of Heparin.

Turner syndrome is the most common chromosomal abnormality in females occurring in 1 in 2500 live births. It is characterised by short stature, webbed neck and wide carrying angle. It is also associated with renal, endocrine and CVS abnormalities. In this condition the ovaries do not completely develop and do not produce oestrogen or oocytes, thus no secondary sexual characteristic develop and neither does the girl starts menstruating.

As the most likely diagnosis, this woman meets diagnostic criteria for premenstrual syndrome (PMS).
Affective and physical symptoms that begin one week before menstruation and end four days after menstrual flow begins are diagnostic criteria for premenstrual syndrome. The symptoms must be present for at least three menstrual cycles and must not occur during the preovulatory period.
It’s critical to note that these symptoms are not caused by any medical or psychological condition, medications, drugs, or alcohol.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent tears, and a lack of interest in daily activities. To put it another way, emotional impairment is the most prominent trait.

This woman does not meet the diagnostic criteria for PMDD because she only has psychological symptoms of irritation and anxiety, as well as physical symptoms of headache and breast soreness (five symptoms).

PMDD diagnostic criteria include:
Symptoms and their timing
A) At least 5 symptoms must be present in the final week before menses, improve within a few days after menses, and become mild or non-existent in the week after menses in the majority of menstrual cycles.
Symptoms
B) At least one of the symptoms listed below must be present:
1) Affective lability that is noticeable (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
2) Excessive irritation, wrath, or interpersonal conflicts
3) Depressed mood, hopelessness, and self-depreciating thoughts
4) Severe anxiety, tension, and/or a sense of being tense or on edge
C) In addition to the symptoms listed in criterion B, one (or more) of the following symptoms must also be present to reach a total of five symptoms.
1) Loss of enthusiasm for customary activities
2) Subjective concentration problems
3) Lethargy, fatigability, or a noticeable lack of energy
4) Significant changes in appetite, such as binge eating or specific food desires
5) Insomnia or hypersomnia
6) A feeling of being overwhelmed or powerless
7) Physical signs and symptoms include breast discomfort or swelling, joint or muscle pain, bloating, or weight gain.
Severity
D)The symptoms are linked to clinically substantial distress or interfere with employment, school, regular social activities, or interpersonal relationships.
E) Think about other mental illnesses. The disturbance isn’t only a sign of another disorder, like major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
Confirmation of the condition
F)Prospective daily ratings throughout at least two symptomatic cycles should be used to confirm Criterion A. (although a provisional diagnosis may be made prior to this confirmation)
Other medical explanations are ruled out.
G) The symptoms aren’t caused by the physiological consequences of a substance (e.g., drug misuse, medication, or other treatment) or a medical condition (e.g., hyperthyroidism).
The severity of the symptoms cannot be explained by normal menstrual physiology.
Generalized anxiety disorder and depression are improbable diagnoses because these symptoms are temporally tied to menstrual cycles.

After perineal repair, lactulose and a bulking agent should ideally be given for 5-10 days as well as broad spectrum antibiotics should be given that will cover all possible anaerobic bacteria. At 6-12 months a full evaluation should be done regarding the progress of healing. 60 to 80% of women are asymptomatic 12 months post delivery and external anal sphincter repair.

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

When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.

Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.

The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.

The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.

it is imperative to elucidate the patient’s risk for current pregnancy and time within her current menstrual cycle prior to IUD insertion. A negative urine pregnancy test is a prerequisite to placement of an IUD. Pregnancies occurring with IUDs in place have an increased incidence of complications, including spontaneous abortion and septic abortion.

For this reason, many providers prefer to time IUD insertion within the first 5-7 days of the menstrual cycle, further assuring that the patient is not newly pregnant.

All other options take risk of the patient being pregnant.

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.

Paracetamol is safe to take during pregnancy and has shown no harm to unborn children during studies. It is the treatment of choice for mild to moderate pain during pregnancy.

The Pudendal provides cutaneous innervation to the posterior external genitalia via one of its terminal branches called the perineal nerve (this further branches into the posterior labial nerves or posterior scrotal nerve in men). The ilioinguinal nerve provides anterior sensation via the anterior labial nerves (anterior scrotal nerve in men). The genital branch of the genitofemoral nerve contributes some fibres to the skin of the mons pubis and labia majora in females. The posterior cutaneous nerve of thigh sometimes overlaps sensory areas.

Antepartum haemorrhage presents with bleeding, which may or may not be accompanied by pain. Uterine irritability would suggest abruptio, however contractions are present which may be confused with uterine irritability and in this case, there are no signs of pre-eclampsia present.

Cilia are small hair line projections in the fallopian tube. Their main function is to transport the egg through he fallopian tube towards the uterus. It is present in many other tubular organs and its function varies accordingly to the organ.

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

Incontinence in women is typically related to dysfunction of the bladder or pelvic floor muscles, with such dysfunction often arising during pregnancy or childbirth, or at the time of menopause.

A pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. The primary host for the organism is the domestic cat. Humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection can lead to hydrocephalus, microcephaly, mental disability and vision loss.

Patient’s symptoms and signs are suggestive of round ligament strain, which is a normal finding during pregnancy, especially in the 2nd trimester, and it does not require any medical intervention.

Round ligament is a rope-like fibromuscular band which extends from the anterolateral aspect of uterus anteriorly between the layers of the broad ligament, and passing through the deep inguinal ring into the inguinal canal.
A sharp, sudden spasm in the right iliac fossa which lasts for a few seconds which is usually triggered by sneezing, coughing, laughing and rolling over in bed are the common presentations of a round ligament pain.

Ectopic pregnancy and rupture of ectopic pregnancy are two unlikely diagnosis in this patient as she is in the second trimester of her pregnancy, whereas both the mentioned conditions occur during the first trimester.

Although appendicitis presents with pain in right iliac fossa, the pain is not causes by coughing or sneezing. Also, there will be other symptoms like tenderness and rebound tenderness in right iliac fossa in case of appendicitis.

Tamoxifen is an oestrogen antagonist in breast tissue but it acts as a partial oestrogen agonist on the endometrium increasing the risk of hyperplasia and has been linked to endometrial cancer. Tamoxifen improves bone density in post-menopausal women. It is an off license treatment for gynaecomastia. Reduced lactation is a potential side effect of Tamoxifen.

Nausea and vomiting experienced in 80% of pregnancies Hyperemesis gravidarum (HG) is an extreme form of nausea and vomiting which affects around 1.5% of women. Caused by high levels HCG. Definitions vary but most consider it to be defined by severe nausea and vomiting associated with weight loss greater than 5% of pre-pregnancy weight with metabolic disturbance (typically dehydration and/or ketosis).

Gestational Diabetes occurs in 2-9% of all the pregnancies.

Congenital cytomegalovirus infections are the most common cause of sensorineural hearing loss in babies. Cytomegalovirus infection during the perinatal period can be transferred to the foetus especially if the primary infection is during pregnancy. Babies born with congenital CMV are either symptomatic or develop symptoms later in life. Some of the features of CMV infection include sensorineural hearing loss, visual impairment, cerebral palsy, microcephaly and seizures. Other causes of infective congenital sensorineural hearing loss include: Rubella, HIV, Herpes Simplex Virus, Measles, Varicella Zoster virus, Mumps and West Nile Virus.

In patients with normal BMI there is no preferential entry method. The Varess technique is not appropriate for morbidly obese or very thin patients for the reasons set out below: Morbid Obesity (BMI>40): Hasson technique or entry at Palmers point Reason: difficult penetration with Varess needle Very Thin Patients: Hasson technique or insertion at Palmers point Reason: higher risk of vascular injury

Contraindications of PROVERA (medroxyprogesterone acetate) include: undiagnosed abnormal genital bleeding, known, suspected, or history of breast cancer, known or suspected oestrogen- or progesterone-dependent neoplasia, active DVT, pulmonary embolism, or a history of these conditions, active arterial thromboembolic disease (for example, stroke and MI), or a history of these conditions, known anaphylactic reaction or angioedema, known liver impairment or disease, known or suspected pregnancy.

Closure of the uterus should be performed in either single or double layers with continuous or interrupted sutures. The initial suture should be placed just lateral to the incision angle, and the closure continued to a point just lateral to the angle on the opposite side. A running stitch is often employed and this may be locked to improve haemostasis. If a second layer is used, an inverting suture or horizontal suture should overlap the myometrium. Once repaired, the incision is assessed for haemostasis and ‘figure-of-eight’
sutures can be employed to control bleeding. Peritoneal closure is unnecessary. Abdominal closure is performed in the anatomical planes with high strength, low reactivity materials, such as polyglycolic acid or polyglactin. Diamorphine is advised for intra and post op analgesia and oxytocin is advised to reduce blood loss.

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.

Urodynamics is a broad term that comprises cytometry, urethral pressure measurement, leak point pressure, pressure flow studies, EMG and videourodynamics. They assess the function of the bladder and urethra as a functional unit. This may provide information such as the site of bladder outlet obstruction, overactivity of the detrusor and sphincter weakness. In muscular terms the detrusor and sphincter muscles are being assessed.

Warfarin inhibits Vitamin K dependent clotting factors. These include factors 2,7,9 and 10.

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.

Repetitive late decelerations can be caused by fetal hypoxia which results in constriction of the vessels to circulate blood from the peripheries to more important organs of the body like the brain and heart etc.

Gestational trophoblastic disease (GTD) is a group of tumours defined by abnormal trophoblastic proliferation. Trophoblast cells produce human chorionic gonadotropin (hCG).

GTD is divided into hydatidiform moles (contain villi) and other trophoblastic neoplasms (lack villi). The non-molar or malignant forms of GTD are called gestational trophoblastic neoplasia (GTN).
Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. Risk factors include extremes of age, ethnicity, and a prior history of an HM which suggests a genetic basis for its aetiology.

GTD is best managed by an interprofessional team that includes nurses and pharmacists. Patients with molar pregnancies must be monitored for associated complications including hyperthyroidism, pre-eclampsia, and ovarian theca lutein cysts. Molar pregnancy induced hyperthyroidism should resolve with the evacuation of the uterus, but patients may require beta-adrenergic blocking agents before anaesthesia to reverse effects of thyroid storm. Pre-eclampsia also resolves quickly after the evacuation of the uterus. Theca lutein cysts will regress spontaneously with falling beta-HCG levels. However, patients must be counselled on signs and symptoms of ovarian torsion and ruptured ovarian cysts.

A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again.

Traditional POP main mode of contraceptive action: thickening of cervical mucus Desogestrel-only POP main mode of contraceptive action is inhibition of ovulation Cerazette® is the only Desogestrel-only POP in the options above. Other desogestrel brands include: Aizea® Cerelle® Nacrez® The other POPs listed are considered traditional POPs and have the following compositions: Norgeston® – Levonorgestrel 30 mcg Micronor® & Noriday® – Norethisterone 350 mcg Femulen® – Ethynediol diacetate 500 mcg

Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously­ normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidy

Maternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two.

RNA viruses are almost always single stranded whilst DNA viruses are almost always double stranded. The exceptions are rotavirus and Parvovirus B19 respectively.

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.

Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.

Induction of Labour is produced by the infusion of PGF-2 alpha or PGE2. Dinoprostone is a PGE2 and is associated with transient pyrexia that resolved within 4-5 hours of stopping the use of the drug.

Pregnant women need to get enough folic acid. The vitamin is important to the growth of the foetus’s spinal cord and brain. Folic acid deficiency can cause severe birth defects known as neural tube defects. The Recommended Dietary Allowance (RDA) for folate during pregnancy is 600 micrograms (µg)/day.

Primary hyperparathyroidism is the most common cause of hypercalcemia. It is usually caused by a tumour of the parathyroid gland. Symptoms are related to increased calcium levels which can cause kidney stones, abdominal groans, psychiatric overtones and bones disease such as osteoporosis,osteomalacia and arthritis.

As they respond differently to different drugs, a thorough distinguishing must be done between the two major groups of epilepsies while approaching a woman, who wishes to become pregnant while on antiepileptic drugs.

Partial epilepsies will respond to most of the antiepileptic drugs, but in case of idiopathic generalized epilepsies, especially in juvenile myoclonic epilepsy, seizure can be controlled only with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful but substitution of sodium valproate with lamotrigine is not the right choice. This is because lamotrigine is not as effective as sodium valproate and will sometimes worsens myoclonic seizures in juvenile myoclonic epilepsy.

Topiramate and levetiracetam are found to be effective in idiopathic generalized epilepsy, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially in myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there will be no effective alternative to sodium valproate as cessation of sodium valproate will lead to recurrence of the generalized seizures, especially juvenile myoclonic epilepsy. Hence, it is not advisable to discontinue the drug in auch patients.

On the other hand, sodium valproate have the highest reported teratogenicity potential among antiepileptic drugs and the Australian Pregnancy Register has reported the risk to be as high as 16% if used in first trimester. Sodium valproate should be avoided in women of reproductive age and if a patient on the medication is willing to become pregnant, she should be well informed about the risk of teratogenicity and the decision must be left to her. If she decides to accept the risks and continue with pregnancy, the lowest possible effective dose should be prescribed to her.

If the dose of sodium valproate has been reduced to minimum during pregnancy to reduce the possible teratogenesis, it is recommended to re-establish the prepartum effective dose before the onset of labor. This is because, it is the time with increased risk for seizures, especially in patients with idiopathic generalised epilepsy who are very sensitive to sleep deprivation. Valproate therapy is found to be safe during breastfeeding.

Thee good news in regard to incontinence after childbirth is that there are many treatment options. Some common treatment options are listed below.

Food and drinks such as coffee, citrus, spicy foods and soda can all irritate the bladder. Cutting back on or eliminating these foods may help improve incontinence symptoms. Keeping weight within a healthy BMI range, and/or focusing on losing pregnancy weight, can also help with bladder control.

Kegels strengthen the pelvic floor, giving more control over urinary urges. Pelvic floor physical therapy can also help build muscle memory and strength. The abdominal muscles, hip muscles and pelvic floor muscles work together when a woman performs strengthening exercises like Kegels. Physical therapists identify areas of weakness in those muscle groups to help a woman build a strong core and pelvic floor.

The bladder is a muscle that should be regularly strengthened. Scheduling urination times and then gradually increasing the amount of time in between urination can increase bladder strength.

Percutaneous tibial nerve stimulation is a nonsurgical treatment for overactive bladder and a form of neuromodulation therapy. During PTNS treatments, a doctor places a slim needle in the ankle where the tibial nerve is located. The needle delivers electrical impulses to the tibial nerve, which sends signals to the sacral nerves in the spine that control bladder and pelvic floor function. Over time, these pulses block nerve signals that are not working properly to lessen urinary incontinence symptoms.

Evaluating lifestyle factors. Excessive coughing due to smoking or being overweight can put unnecessary strain on the pelvic floor muscles. Certain drugs such as antidepressants and antihistamines can also have an impact on urinary incontinence.
Pessary. A pessary is a device inserted into the vagina to provide support for vaginal tissues, in turn, aiding in bladder incontinence.

Surgical treatment options can help support the pelvic floor and may be recommended for women who have completed childbearing and have not had success with conservative therapy.

It has been found that it is possible for premenopausal hormones to persist for a period of time after attaining menopause. If one or a few ovarian follicles remain, they could produce oestrogen in response to the very elevated levels of FSH typically seen in menopause. In doing so, the woman can then bleed as a result of this physiological response. The symptoms seen in this vignette are consistent with the rise in oestrogen levels, likely due to follicular activity.

In the absence of any pathological findings such as endometrial carcinoma, this phenomenon would be the most likely cause of this post-menopausal bleed. Furthermore, it is unlikely for cervical cancer and endometrial cancer to present during the first few years following menopause. Atrophic vaginitis is unlikely to be associated with the other symptoms the patient presented with i.e. reduction in the intensity of hot flushes and breast enlargement. This patient was not stated to have any risk factors for endometrial hyperplasia such as obesity, late menopause and early menarche, which makes it a less likely diagnosis.

Placental abruption is commonly defined as the premature separation of the placenta, which complicates approximately 1% of births. During the second half of pregnancy abruption is considered an important cause for vaginal bleeding and is mostly associated with significant perinatal mortality and morbidity.
Clinical presentation of abruption varies from asymptomatic cases to those complicated with fetal death and severe maternal morbidity. Classical symptoms of placental abruption are vaginal bleeding and abdominal pain, but at times severe cases might occur with neither or just of one of these signs. In some cases the amount of vaginal bleeding may not correlates with the degree of abruption, this is because the severity of symptoms is always depend on the location of abruption, whether it is revealed or concealed and the degree of abruption.
Diagnosis of abruption is clinical and the condition should be suspected in every women who presents with vaginal bleeding, abdominal pain or both, with a history of trauma, and in those women who present with an unexplained preterm labor. All causes of abdominal pain and bleeding, like placenta previa, appendicitis, urinary tract infections, preterm labor, fibroid degeneration, ovarian pathology and muscular pain are considered as differential diagnosis of abruption.

In the given case patient has developed signs and symptoms of placental abruption, like severe vaginal bleeding with abdominal pain, whose management depends on its presentation, gestational age and the degree of maternal and fetal compromise. As the presentation is widely variable, it is important to individualize the management on a case-by-case basis. More aggressive management is desirable in cases of severe abruption, which is not appropriate in milder cases of abruption. In cases of severe abruption with fetal death, as seen in the given case, it is reasonable to allow the patient to have a vaginal delivery,regardless of gestational age, as long as the mother is stable and there are no other contraindications.
The uterus is contracting vigorously, and labor occurs rapidly and progresses, so amniotomy is mostly sufficient to speed up delivery. There is a significant risk for coagulopathy and hypovolemic shock so intravenous access should be established with aggressive replacement of blood and coagulation factors. Meticulous attention should be paid to the amount of blood loss; general investigations like complete blood count, coagulation studies and type and crossmatch should be done and the blood bank should be informed of the potential for coagulopathy. A Foley catheter should be placed and an hourly urine output should be monitored.
It is prudent to involve an anesthesiologist in the patient’s care, because if labor does not progress rapidly as in cases like feto-pelvic disproportion, fetal malpresentation, or a prior classical cesarean delivery, it will be necessary to conduct a cesarean delivery to avoid worsening of the coagulopathy.
Bleeding from surgical incisions in the presence of DIC may be difficult to control, and it is equally important to stabilize the patient and to correct any coagulation derangement occuring during surgery. The patient should be monitored closely after delivery, with particular attention paid to her vital signs, amount of blood loss, and urine output. In addition, the uterus should be observed closely to ensure that it remains contracted and is not increasing in size.
Immediate delivery is indicated in cases of abruption at term or near term with a live fetus. In such cases the main question is whether vaginal delivery can be achieved without fetal or maternal death or severe morbidity. In cases where there is evidence of fetal compromise, delivery is not imminent and cesarean delivery should be performed promptly, because total placental detachment could occur without warning.

Endometrial hyperplasia with atypia is at high risk of progression to cancer and hysterectomy is indicated There is high risk of progression to cancer with endometrial hyperplasia with atypia and hysterectomy is indicated. Although weight loss would be beneficial this shouldn’t delay surgical management.

Remember the inferior rectal artery supplies the anus. The middle rectal artery is the principle supply to the lower 1/3 rectum. The rectal arteries do form an anastomosis.

This patients bloods and symptoms suggest she has hepatic impairment. Acute fatty liver of pregnancy typically presents after the 30th week. The usual symptoms in the mother are non-specific including nausea, vomiting, anorexia (or lack of desire to eat) and abdominal pain; excessive thirst may be the earliest symptom without overlap with otherwise considered normal pregnancy symptoms; however, jaundice and fever may occur in as many as 70% of patients.

Many laboratory abnormalities are seen in acute fatty liver of pregnancy. Liver enzymes are elevated, with the AST and ALT enzymes ranging from minimal elevation to 1000 IU/L, but usually staying in the 300-500 range. Bilirubin is almost universally elevated. Alkaline phosphatase is often elevated in pregnancy due to production from the placenta, but may be additionally elevated. Other abnormalities may include an elevated white blood cell count, hypoglycemia, elevated coagulation parameters, including the international normalized ratio, and decreased fibrinogen. There may be increases of ammonia, uric acid aswell.

Recent studies have shown that being a primigravida, multiple pregnancies, carrying a male fetus, other liver diseases during pregnancy, previous history of AFLP, and pre-eclampsia are the potential risk factors for AFLP

Dehydroepiandrosterone (DHEA) is a steroid hormone synthesised from cholesterol (via Pregnenolone) by the adrenal glands. The foetus manufactures DHEA, which stimulates the placenta to form oestrogen, thus keeping a pregnancy going. Production of DHEA stops at birth, then begins again around age seven and peaks when a person is in their mid-20s