Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.

Retarded skeletal growth resulting in small for gestational age babies are the usual outcomes of an untreated vitamin D deficiency in pregnancy.

Symptoms associated with maternal vitamin D deficiency during pregnancy are:
– Hypocalcemia in newborn.
– Development of Rickets later in life.
– Defective tooth enamel.
– Small for gestational age due to its effect on skeletal growth
– Fetal convulsions or seizures due to hypocalcemia.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication for suppression of labour.
Suppression of labour known as tocolysis is contraindicated in situations like suspected foetal compromise, which is diagnosed by cardiotocograph warranting delivery, in cases of placental abruption, in chorioamnionitis, in severe pre-eclampsia, cases were gestational age is more than 34 weeks, in cases of foetal death in utero and in cases where palliative care is planned due to foetal malformations.

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.

Lichen sclerosis (LS) is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by symptoms of pruritus and pain.

Topical corticosteroids are the mainstay of therapy. Intralesional corticosteroid therapy is an additional option that is useful for the treatment of thick hypertrophic plaques that topical corticosteroids may not penetrate adequately.

Antibiotics or antifungals have no role in the treatment of LS since it’s not an infection.
Since histological diagnosis has already been made, there is no need to refer to dermatologist.
Surgical intervention is indicated for treatment of complications like adhesion and scarring.

The best regimen would be to have no intercourse in the follicular phase of the cycle and then commence it two days after a temperature rise of 0.3C and continue then onwards. When deciding the best contraceptive method, one has to consider two factors-the duration of survival of sperm in the uterus and body temperature in relation to ovulation. For this case, since her cycle length varies from 24 to 30 days, the earliest time in which ovulation would occur would be 14 days before her shortest cycle i.e. day 10. Intercourse has to be avoided from day 4 of her cycle just in case the current cycle is short because sperm can survive up to 6 days in the uterus. Day 4 would be the day her menses would end and as this couple avoids intercourse during her menstruation, there would be no intercourse during the follicular phase of her cycle.

During ovulation, her serum progesterone levels would start to increase, causing a 0.3°C to 0.4°C increase in her body temperature within 2-3 days of ovulating. This elevation in temperature would remain until close to when her period starts. The ovum can only be fertilised for roughly 24 hours after ovulation has taken place. Resuming sexual intercourse once her temperature has risen for 2 days would suggest that ovulation had already taken place 3-4 days earlier and so it is unlikely for pregnancy to occur.

Options that include intercourse during any part of her follicular phase is not correct. Hence, the only option that satisfies the above criteria would be intercourse avoidance during her follicular phase and to resume 2 days following a rise of 0.03°C in body temperature.

CMV effects 1 in 200 pregnancies of which 30% will transmit the virus to the foetus and of which 30% foetus will be effected.

At the 36‑week appointment, all pregnant women should be seen again. At this appointment: measure blood pressure and test urine for proteinuria; measure and plot symphysis–fundal height; check position of baby; for women whose babies are in the breech presentation, offer external cephalic version (ECV)

Desogestrel only POPs work mainly by inhibiting ovulation. Cerazette Is the only brand in this list which belongs to this group.

Types of Progesterone Only Pills

1. Traditional (e.g. Femulen®, Micronor®, Norgeston®)

Main mode of action: thickening cervical mucus preventing sperm entry at neck of womb and may also cause anovulation but this effect variable and unreliable

2. Desogestrel (e.g. Cerazette®)

Main mode of action: inhibition of ovulation and also cause thickening of cervical mucus

Her T-score puts her in the osteopenic range. The presence of fragility fractures is more important in the osteoporotic patient. Olecranon fracture is not a typical fragility fracture.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

Multiple pregnancy is considered a high risk for obstetric complications such as spontaneous abortion, hypertensive disorders, placenta previa, and fetal malformations. Specifically, the incidence of hypertensive disorders, a common source of maternal morbidity, is 15% to 35% in twin pregnancies, which is two to five times higher than in singleton pregnancies. Additionally, the aetiology of preterm birth is not completely understood, but the association between multiple pregnancy and preterm birth is well known. A secondary analysis of the WHO Global Survey dataset indicated that 35.2% of multiple births were preterm (< 37 weeks gestation); of all multiple births, 6.1% of births were before 32 weeks gestation, 5.8% were during weeks 32 and 33, and 23.2% were during weeks 34 through 37

The genitofemoral nerves takes its origin from the L1 and L2 spinal segments.

Genital folds lead to the formation of the scrotum in males while in females they form the posterior labial commissure. Genital tubercles form the labia majora whereas the tubercle itself becomes the mons pubis. The labia minora is formed by the urogenital folds.

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.

1. First-degree trauma corresponds to lacerations of the skin/vaginal epithelium alone.
2. Second-degree tears involve perineal muscles and therefore include episiotomies.
3. Third-degree extensions involve any part of the anal sphincter complex (external and internal sphincters):
i Less than 50 per cent of the external anal
sphincter is torn.
ii More than 50 per cent of the external anal
sphincter is torn.
iii Tear involves the internal anal sphincter
(usually there is complete disruption of the
external sphincter).
4. Fourth-degree tears involve injury to the anal sphincter complex extending into the rectal mucosa.

HPV 16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV. As well as cervical cancer they are associated with cancers of the oropharynx and anogenital region.

There are over 100 genotypes of HPV including several other high risk HPV types. Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18

HPV genotypes 6 and 11 are low risk and cause anogenital warts.

Typically 70% of HPV infections are cleared within 1 year and 90% are cleared within 2 years

Oxytocin is responsible for the let down mechanism that occurs during breast feeding in which the myothelial cells contract and push the milk into the ductules.

The femoral triangle is bounded superiorly by the inguinal ligament which forms the base of the triangle, medially by the lateral border of the adductor longus and laterally by the sartorius muscle.

Disseminated intravascular coagulation (DIC) in pregnancy is the most common cause of an abnormal haemorrhage tendency during pregnancy and the puerperium. Although pregnancy itself can cause DIC, its presence is invariably evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead foetus, amniotic fluid embolism, placental retention or bacterial sepsis.

Patient mentioned in the case has developed thyrotoxicosis during pregnancy. TSH level should be tested, and if the result shows any suppressed or elevated TSH level, then it is mandatory to check for free T4 level.

IgM rise is typically seen with acute infection. IgG is produced in response to infection but is produced later than IgM. IgG is also produced in response to vaccination. If IgG and IgM are negative the patient is susceptible to Rubella infection. If IgG +ve and IgM -ve the patient should be considered immune. If IgM +ve this suggests acute infection or false positive IgM (not uncommon)

When there are about 12-32 blastomeres, the developing human is referred to as morula. It enters the uterine cavity around the 4th day after fertilization.

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

Premenopausal women with asymptomatic simple cysts smaller than 8cm on sonograms in whom the CA125 value is within the reference range may be monitored, with a repeat ultrasonographic examination in 8-12 weeks.

Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts should be considered for surgical removal.

For this patient, a premenopausal woman, with an ovarian cyst size 8 cm x 12cm. Surgical management is indicated, hence referral to gynaecologist is appropriate.

Laparotomy or laparoscopic excision of cyst should be considered and performed by the gynaecologist not general practitioner.

The femoral triangle is bounded superiorly by the inguinal ligament which forms the base of the triangle, medially by the lateral border of the adductor longus and laterally by the sartorius muscle.

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

The urinary bladder is composed of the transitional epithelium, followed by the lamina propria made up of the fibroelastic connective tissue. The muscularis layer covers the lamina propria which is made up of three poorly defined layers of smooth muscles; the inner longitudinal, middle circular and the outer longitudinal layer. The bladder is covered on the superior surface and the lateral surface by the peritoneum.

Sertoli cells contain receptors for FSH. In response to this Sertoli cells synthesize inhibin, androgen binding proteins and anti Mullerian hormone all which are connected to the reproduction cycle.

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.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 weeks old and is replaced by adult haemoglobin by the age of 5 months post natally.