Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.

Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

Protein C, protein S, plasminogen and anti thrombin III are all anti thrombotic agents. Thromboplastin is a pro-thrombotic.

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.

The patient most likely suffered a uterine rupture. It occurs most often in multiparous women and is less often associated with external haemorrhage. Shock develops shortly after rupture due to the extent of concealed bleeding.

Uterine inversion rarely occurs when after a spontaneous and normal third stage of labour. Although it can lead to shock, it is usually associated with a history of controlled cord traction or Dublin method of placenta delivery before the uterus has contracted. This diagnosis is also strongly considered when shock is out of proportion to the amount of blood loss.

An overwhelming infection is unlikely in this case when labour occurred for a short period of time. Uterine atony and amniotic fluid embolism are more associated with excessive vaginal bleeding, which is not evident in this case.

It utilizes the IgG class of the antibody.

After the release of the oocyte, the theca and the granulosa cells form the corpus luteum which undergoes extensive vascularization for continued steroidogenesis. Progesterone is secreted by the luteal cells and is synthesized from cholesterol. The luteal phase lasts for 14 days and if implantation does not occurs the corpus luteum starts to degenerate. As B-HCG produced by the implanted embryo maintains it and without it luteolysis occurs.

Promethazine is type of antihistamine that acts on the H1 receptor. In pregnancy NICE guidelines advise oral promethazine or oral cyclizine should be used as 1st line drug management of nausea and vomiting. Both are H1 antagonists.

Multiple studies have identified several risk factors for uterine atony such as polyhydramnios, fetal macrosomia, twin pregnancies, use of uterine inhibitors, history of uterine atony, multiparity, or prolonged labour.

The anterior aspect of the vulva (mons pubis, anterior labia) is supplied by derivatives of the lumbar plexus: the anterior labial nerves, derived from the
ilio-inguinal nerve, and the genital branch of the genitofemoral nerve.
The posterior aspect of the vulva is supplied by derivatives of the sacral plexus: the perineal branch of the posterior cutaneous nerve of the thigh laterally, and the pudendal nerve centrally.

Hyaline degeneration is the most common form of fibroid degeneration. Fibroids:
Risk Factors
– Black Ethnicity
– Obesity
– Early Puberty
– Increasing age (from puberty until menopause)
Protective Factors
– Pregnancy
– Multiparity

Women with diabetes have increased risk for adverse maternal and neonatal outcomes and similar risks are present for either type 1 or type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies, and to minimize risk of congenital defects. Haemoglobin A1c goal at conception is <6.5% and during pregnancy is <6.0%.

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.

Serous tumours of the ovaries are large, cystic and spherical to ovoid in shape. They can be benign or malignant. Malignant tumours are usually nodular with irregularities in the surface where the tumour penetrates into the serosa. Psammoma bodies are a histological identification for these tumours which appear in the tips of the papillae.

This woman suffers from a classic migraine with focused neurological symptoms. The use of any OCP preparation containing oestrogen in such patients is strictly prohibited. Androgenic consequences of progesterone include hirsutism, acne, and weight gain. Progesterone of any sort (norgestrel, drospirenone, cyproterone, etc.) should be avoided by a lady of her size; consequently, a barrier approach such as male condoms is the best option.

It is recommended that formulations containing 20-30 mcg ethinylestradiol be evaluated first when choosing a combined oral contraceptive pill (COCP). The progesterone component can be norgestrel, drospirenone, cyproterone, and so on; however, norgestrel-containing formulations are less expensive and more accessible to patients.

For specific cases, the type of progesterone should be considered:
– Patients who have unpleasant fluid retention and weight gain as a side effect of COCPs may be administered drospirenone (Yaz®. Yasmin®)-containing preparations.
– Drospirenone inhibits the production of mineralocorticoids and does not cause fluid retention. It may even be linked to a small amount of weight reduction.
– A preparation containing cyproterone acetate is preferable if the patient has suspected polycystic ovarian syndrome (PCOS).

Shortly after the Morula enters into the uterus, approximately on the 4th day after fertilization a fluid filled cystic cavity appears in the morula and transforms the morula into a blastocyst.

Typically fetal movements become apparent by 18-20 weeks

Vitamin B1 deficiency can lead to Wernicke’s encephalopathy. Alcoholics are at particular risk. In obstetrics all women with hyperemesis gravidarum should receive thiamine supplementation to prevent Wernicke’s.

Diastolic murmurs should be considered pathological until proven otherwise. The following are common and typically benign findings in pregnancy: A third heart sound after mid-pregnancy. Systolic flow murmurs are common. Left axis deviation on ECG is common, Sagging ST segments and inversion or flattening of the T wave in lead III may also occur

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

The use of lamotrigine during pregnancy has not been associated with an increased risk of neural tube defects; however, the recommendation regarding higher doses of folic acid supplementation is often, but not always, broadened to include women taking any anticonvulsant, including lamotrigine.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

Rubella infection during pregnancy may lead to miscarriage, intrauterine fetal demise, premature labour, intrauterine growth retardation, and congenital rubella syndrome. The risk of developing complications is highest if the infection is contracted within the first 12 weeks of gestation.

In those cases in which a pregnant woman has been exposed to a suspected rubella case, a specimen of blood should be tested as soon as possible for the measurement of rubella-specific IgG antibodies. If it is positive, then the woman was likely to be immune and could be reassured. If it is negative, a determination rubella-specific IgG and rubella-specific IgM antibodies should be obtained in 3 weeks to exclude an asymptomatic primary rubella infection.

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.

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.

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

Placental abnormalities such as placenta previa and placenta accreta are the most common reasons for considering hysterectomy as an inevitable treatment option in postpartum hemorrhage.

Placental villi normally invade only the superficial layers of endometrial deciduas basalis, but when the invasion is too deep into the uterine wall, the condition is termed as placenta accreta, increta or percreta depending on the depth of invasion.
– When the villi invade the deeper layers of the endometrial deciduus basalis, but not the myometrium it is called as Placenta accreta. This is the most common type of decidual invasion and accounts for approximately 75% of the cases.
– When the villi invade the myometrium, but do not reach the uterine serosa or the bladder is called Placenta increta. This type accounts for nearly 15% of cases.
– In cases were the villi invades into the uterine serosa or the bladder is it called as Placenta percreta and this happens in 5% of cases.

Prior uterine surgery is the main risk factor for placenta accreta and the best management is elective cesarean hysterectomy.
postpartum hemorrhage can also be caused by conditions like genital lacerations, uterine atony, retained products of conception and uterine inversion. In most of these above mentioned cases, hysterectomy is not required and remains as the last resort in extremely desperate situations.

NOTE– Though uterine atony is the most common cause of postpartum hemorrhage, it is often manageable medically.

The female pelvic inlet tilts at an inclination that is about 60 degrees from the anatomical horizontal plane. This tilt is maintained by muscles and fascia. The pelvic outlet slopes at an angle of 15 degrees.

This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.

For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.

If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.

A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.

Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.

Amniotic fluid volume begins to increase rapidly in the second and third trimester as the fetal kidneys continue to develop. By 35 weeks gestation the amniotic fluid volume reaches a maximum average of about 800 ml after which it decreases slightly to term.