Engagement means when the fetal head enters the pelvic brim/inlet and it usually takes place 2 weeks before the estimated delivery date i.e. at 38 weeks of pregnancy.

When testing for ovulation the best test is to check the progesterone level. The mid luteal progesterone levels should be checked 7 days prior to the next period. That will be the 28th day in a 35 day cycle.

In early pregnancy Progesterone is produced by the corpus luteum.. This organ is fundamental for pregnancy maintenance until the placenta (syncytiotrophoblast) takes over its function at the 7-9th week of gestation, just after the expression of major histocompatibility complex antigens is suppressed in extra-embryonic fetal tissue.

Secondary postpartum hemorrhage of bright red character accompanied with fever, between 24 hours to 12 weeks of postpartum is suggestive of retained products of conception (RPOC).
The basal portion of the decidua may remain after separation of placenta in many cases. This decidua will then divides into two layers, the superficial layer which will be shed spontaneously and the deep layer which will regenerates and covers the entire endometrial cavity with in 16 days of postpartum.
Normal shedding of blood and decidua is referred to as lochia rubra, which is red / reddish brown in colour and it lasts for few days following delivery. This vaginal discharge gradually becomes watery and pinkish brown in colour, lasting for 2 to 3 weeks and is called as lochia serosa. Ultimately, this discharge becomes yellowish-white called as lochia alba.

Scanty lochia in the first few days after delivery is suggestive of the placental site not undergoing involution, which occurs mostly due to RPOC. Later these retained products will undergo necrosis resulting in fibrin deposition which will eventually form a placental polyp. Detachment of this scar of polyp will result in brisk hemorrhage and the remaining necrotic products will get infected resulting in uterine infection which will present with fever, lower abdominal pain and uterine tenderness.

Endometritis can lead to fever, offensive lochia and abdominal pain with tenderness. It is the most common cause of postpartum fever, but occurs within the first 5 days of postpartum with the peak incidence between days 2 and 3. Though vaginal bleeding is a presenting feature, bright red bleeding is unlikely of endometritis.

Another cause of postpartum fever is genital lacerations which have a peak incidence of wound infection between 4th and 5th days. Although fever as a temporal symptom favours wound infection, this diagnosis is less likely in the given case as wound infection will not affect the normal course of lochia, also it does not present as heavy bright red bleeding. Moreover, there are no symptoms like erythema, tenderness or discharge in history suggestive of wound infection.

Another cause of bleeding and fever can be cervical tear but this tends to present as primary postpartum hemorrhage rather than secondary, which occurs after 24 hours of postpartum. An overlooked and infected minor cervical laceration can cause fever but ii will not result in bright red bleeding, also genital tract lacerations do not affect lochia.

It is very unlikely for uterine rupture to occur 24 hours after delivery.

In the given case pre-pregnancy counselling and management of chronic hypertension is very much essential.
Some commonly prescribed antihypertensive drugs like ACE inhibitors, angiotensin receptor antagonists, diuretics and most beta blockers are contraindicated or is best to be avoided before conception and during pregnancy.
Methyldopa is considered as the first line drug for the management of mild to moderate hypertension in pregnancy and is the most commonly prescribed antihypertensive for this indication.
Hydralazine can be used during any hypertensive emergencies in pregnancy.
Intake of Angiotensin receptor blockers and ACE inhibitors during the first trimester can lead to complications as they are both teratogenic; use of these drugs during second and third trimesters can result in foetal renal dysfunction, oligohydramnios and skull hypoplasia.
Diuretics can cause foetal electrolyte disturbances and significant reduction in maternal blood volume.
All beta blockers, except labetalol, can result in foetal bradycardia, and growth restriction in case its long-term use.
Calcium channel antagonists, except nifedipine, are avoided during pregnancy due to its high risk for maternal hypotension and foetal hypoxia.

Premenstrual dysphoric disorder (PMDD) is a more serious form of premenstrual syndrome (PMS). PMS causes bloating, headaches, and breast tenderness a week or two before your period.

With PMDD, you might have PMS symptoms along with extreme irritability, anxiety, or depression. These symptoms improve within a few days after your period starts, but they can be severe enough to interfere with your life.

PMDD symptoms appear a week or two before menstruation and go away within a few days after your period starts. In addition to PMS symptoms, you may have:

Anger or irritability.
Anxiety and panic attacks.
Depression and suicidal thoughts.
Difficulty concentrating.
Fatigue and low energy.
Food cravings or binge eating.
Headaches.
Insomnia.
Mood swings.

The following treatments have been shown to relieve symptoms:

Sertraline, escitalopram, paroxetine, and fluoxetine are SSRIs (selective serotonin reuptake inhibitors). SSRIs are the first-line treatment and are extremely effective.
The second line of defence is alprazolam (a short course recommended due to its addictive potential).
The use of temazepam has little advantage because it only aids with sleep and is relatively short-acting.
Lifestyle modifications-weight loss, exercise, quitting smoking, and relaxation therapies for less severe PMS.
Danazol-suppresses the ovulation and helps with mastalgias associated with PMS.

The yolk sac increases in size up until the 10th week reaching a maximum diameter of 6mm in normal pregnancy. After the 10th week the yolk sac will gradually disappear. It is usually sonographically undetectable by 20 weeks. A yolk sac greater than 6mm diameter is suspicious of failed pregnancy.

This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.

There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.

The risk of transplacental transmission from mother to foetus is greater in later pregnancy i.e. 26-40 weeks. Although the risk of transmission is lower in early pregnancy, if infection does occur earlier, particularly before 10 weeks, then complications are typically more severe.

Androgen insensitivity syndrome means that patients are phenotypically males but they are resistant or insensitive to male androgen hormones. They do not have a uterus. Due to insensitivity to androgens these patients often have female traits but their genetic makeup is of male, 46XY.

There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria

The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.

Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.

Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.

At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.

Osteogenesis imperfect is an autosomal dominant condition. All the rest of the options are autosomal recessive conditions.

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

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.

Progesterone gradually increases during the course of pregnancy, from 25 ng⋅mL−1 at 6 weeks’ to 150 ng⋅mL−1 at 37 weeks’ gestation. Progesterone acts as trigger of the primary respiratory centre by increasing the sensitivity of the respiratory centre to carbon dioxide, as indicated by the steeper slope of the ventilation curve in response to alveolar carbon dioxide changes. Progesterone alters the smooth muscle tone of the airways resulting in a bronchodilator effect. It also mediates hyperaemia and oedema of mucosal surfaces, causing nasal congestion.

The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. Pregnancy is a state of increased requirement of macro and micronutrients, and malnourishment or inadequate dietary intake before and during pregnancy, can lead to adverse perinatal outcomes. Many nutritional interventions have been proposed for pregnant mothers. These include multiple micronutrients (MMN), iron/folate, balanced protein energy, calcium, zinc and folic acid supplementation.

Breech presentation refers to the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first.

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the foetus to turn into the vertex presentation in the third trimester include:
– Mullerian anomalies
– Placentation
– Uterine leiomyoma
– Prematurity
– Aneuploidies and fetal neuromuscular disorders
– Congenital anomalies
– Polyhydramnios and oligohydramnios
– Laxity of the maternal abdominal wall.

The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.

Girls with Turner’s syndrome (45,X) are not at risk for malignancy. Patients with feminizing testicular syndrome with XY chromosome composition and patients with mixed gonadal dysgenesis are at risk for malignancy, and bilateral gonadectomy is performed.

All non-sensitised RhD negative women should receive Anti-D IgG within 72 hours following abortion

Pelvic organ prolapse is a common condition amongst ageing women where a weakness in the pelvic support structures of the pelvic floor allows pelvic viscera to descend.
The Pelvic Organ Prolapse Quantification system (POP-Q) is useful for describing and staging the severity of the pelvic organ prolapse.
Grade 1: the most distal portion of the prolapse is more than 1 cm above the level of the hymen
Grade 2: the most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Grade 3: the most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (for example, not all of the vagina has prolapsed)
Grade 4: vaginal eversion complete

Patient’s presentation and physical examination findings are most consistent with physiologic dyspnea, which is common during pregnancy. This breathing difficulty which is due to an increase in the tidal volume of lung will present itself as an increased awareness of breathing and can occur as early as the end of first trimester. Any minute increase in the ventilation occurs during pregnancy can make patients feel as if they are hyperventilating and contribute to the feeling of dyspnea.

Patient should be reassured and educated regarding these normal changes of pregnancy, also should be counselled to modify her exercise regimen accordingly to her changed tolerance.

Systolic ejection murmurs are due to increased blood flow across the aortic and pulmonic valves which is a normal finding in a pregnancy. So there is no need for this patient to be referred to a cardiologist or to order an ECG.
About 1 in 6400 pregnancies present with pulmonary embolism and there will be clinical evidence of DVT in many of these cases. Dyspnea, chest pain, apprehension, cough, hemoptysis, and tachycardia are the most common symptoms of PE and physical examination shows accentuated pulmonic closure sound, rales, or a friction rub. If there is a strong suspicion for PE, the patient should be followed up with a ventilation-perfusion scan, which will confirm PE if presented with large perfusion defects and ventilation mismatches.

An elevation in serum PRL is associated with a variety of reproductive disorders, including amenorrhea, oligomenorrhea, anovulation and/or luteal phase defects with subsequent infertility.

If a cervical screening test reveals invasive squamous cell carcinoma or adenocarcinoma, refer the patient to a gynaecologist at a tertiary hospital right once for further treatment.
Colposcopy at a GP practice is not appropriate in these situations. When it comes to the prospect of cancer, reassurance isn’t enough.

The best time of the episiotomy is when the presenting part becomes visible during the contractions. If the episiotomy is performed at the proper time, less time will be required for the delivery. However, if its done too late, it causes excessive stretching of the pelvic floor and further potential lacerations.

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

The substructures of the nephrons are mainly located within the cortex. The JGA sits next to the glomerulus in the cortex (click on the magnifying glass of the image to see the arrangement). They play an important role in blood pressure homeostasis as the juxtaglomerular cells produce renin. The descending and ascending limbs of the loop of Henle and collecting ducts have sections within both the cortex and medulla

The Conjoint tendon AKA Inguinal falx reinforces the posterior wall of the inguinal canal. The inguinal ligament is part of the floor.
The aponeurosis of external oblique is the major component of the anterior wall with fibres of internal oblique reinforcing the lateral part

Ovarian cancer is a gynaecological cancer that commonly affects women over 40 years. Risk factors for ovarian cancer include: infertility, a family history of ovarian, breast or colorectal cancer. There are some protective factors, which include: high parity and breastfeeding, early age at menarche and late age at menopause, and combined oral contraceptives, and statins.

Most common risk factors for spontaneous abortion are considered to be:
– Age above 35 years.
– Smoking.
– High intake of caffeine.
– Uterine abnormalities like leiomyoma, adhesions.
– Viral infections.
– Thrombophilia.
– Chromosomal abnormalities.
Conditions like subclinical thyroid disorder, subclinical diabetes mellitus and retroverted uterus are not found to cause spontaneous abortions.
The term retroverted uterus is used to denote a uterus that is tilted backwards instead of forwards.