All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

Maximum levels of progesterone are detected at day 21 of 28 days in the menstrual cycle, assuming that ovulation has occurred at day 14. A value of >30nmol/l indicates an ovulatory cycle.

Bicornuate uterus is associated with an increased chance of urinary tract anomalies. Urinary tract anomalies were present in about 23.6% of cases of bicornuate uterus patients.

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

In this case, induction of labour at 37 weeks of gestation was necessary due to the absence of spontaneous of labour 24 hours after rupture of membranes. High doses of Syntocin and large volume of fluids may be required particularly when induction is done before term.

Syntocin infusion can lead to uterine hypertonus and tetany which can result in fetal distress at any dosage. This is a common reason to decrease or stop the infusion and an indication for Caesarean delivery due to fetal distress

Uterine rupture can occur as a result of Syntocin infusion especially when the accompanying fluids do not contain electrolytes, which puts the patient at risk for water intoxication.

Maternal hypotension results from Syntocin infusion, not hypertension.

Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery that is why it should be avoided.

Choriocarcinoma may arise as a complication of gestation or as spontaneous germ cell tumours. As this scenario depicts that the women has previous abortion points to the fact that these may have been molar pregnancies. As choriocarcinoma can arise from a molar pregnancy it can be differentiated from it by the presence of invasion into the uterus and metastasis to the lungs primarily.

This patient should have an endometrial biopsy (SOR C). Approximately 7% of postmenopausal women with benign endometrial cells on a Papanicolaou smear will have significant endometrial pathology. None of the other options listed evaluate the endometrium for pathology. An asymptomatic premenopausal woman with benign endometrial cells would not need an endometrial evaluation because underlying endometrial pathology is rare in this group.

Pelvic Outlet Boundaries Anteriorly: Pubic arch Laterally: Ischial tuberosities Posterolaterally: Inferior margin of the sacrotuberous ligament Posteriorly: Tip of the coccyx Note: The pelvis outlet is also called the inferior aperture. The pelvic brim is the superior aperture

Women with polycystic ovary syndrome (PCOS) have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed oestrogen that results from anovulation.

Additionally, secretory endometrium of some women with PCOS undergoing ovulation induction or receiving exogenous progestin exhibits progesterone resistance accompanied by dysregulation of gene expression controlling steroid action and cell proliferation.

Other risk factors include nulliparity, early menarche and late menopause, obesity and family history of endometrial cancer. Which rules out all the other options.

The pelvic outlet is bounded anteriorly by the inferior border of the pubic arch, posteriorly by the sacrotuberous ligament and the tip of the coccyx and laterally by the ischial tuberosities.

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.

Molding allows the skull bones of the fetal head some mobility during the normal delivery of foetus as the skull changes its shape to accommodate passage through the mothers pelvis. However this does not occur in breach delivery where the skull is in circular shape. Babies born breech typically have craniofacial and limb deformations resulting from their in utero position. These babies characteristically have a long, narrow head, (“dolichocephaly” or “type 1”), with a prominent occipital shelf, redundant skin over the neck, overlapping lambdoidal sutures, and an indentation below their ears (from shoulder compression).

A complication of bilateral salpingo-oophorectomy and hysterectomy is the formation of adhesions in the GIT that can cause intestinal obstruction. Abdominal X-ray is sufficient to visualize any obstruction in the GIT.

Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and oestrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis. A woman is diagnosed with polycystic ovaries (as opposed to PCOS) if she has 20 or more follicles in at least 1 ovary. The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following:
Hirsutism
Infertility
Obesity and metabolic syndrome
Diabetes
Obstructive sleep apnoea

Drugs used in the treatment of polycystic ovarian syndrome (PCOS) include metformin (off-label use), spironolactone, eflornithine (topical cream to treat hirsutism), and oral contraceptives. Oral contraceptives containing a combination of oestrogen and progestin increase sex hormone–binding globulin (SHBG) levels and thereby reduce the free testosterone level. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels are also suppressed. This restores cyclic exposure of the endometrium to oestrogen-progestin, with the resumption of menstrual periods and decreased hirsutism.

Drug of choice for treatment of PCOS are COCs, all other options are incorrect.

This patient who is at her 29 weeks of pregnancy, presented with sudden gush of clear fluid and Speculum examination has confirmed premature rupture of membrane (PROM).

Approximately, 50% of PROM progress to labour within 24 hours and in the remaining, 80% within seven days. The most important next step of management in this case is transferring this patient to tertiary care hospital as soon as possible. It is equally important to give corticosteroid therapy, like Betamethasone, if delivery prior to 34 weeks is likely to occur, as it will help in fetal lung maturity.

Cardiotocography (CTG) is usually not available in general practice settings and it can be done only while in the hospital. If CTG shows any abnormality or if there is any presence of infection it is better to induce labor.

Salbutamol and nifedipine are of no use in this case, as the patient is not in labour and does not require tocolytics.

The World Health Organisation defines the maternal mortality ratio as the number of maternal deaths during a given period per 100,000 live births during the same period. This measure indicates the risk of death in a single pregnancy.

Routine ultrasonography at around 18-22 weeks gestation has become the standard of care in many communities. Acceptance is based on many factors, including patient preference, medical-legal pressure, and the perceived benefit by physicians. However, rigorous testing has found little scientific benefit for, or harm from, routine screening ultrasonography.

Patient mentioned above is a known case of type 2 diabetes which makes her at high risk of having neural tube defects. She should be advised to start taking a high dose of (5mg) folic acid supplement daily for at least 1-month prior to conception and it should be continued upto 12 weeks of her pregnancy.

Folate, which is a water-soluble B vitamin, is usually obtained from diet or through supplementation. For those patients with a history of type 2 diabetes mellitus, who are planning for pregnancy, high doses are recommended to prevent any possible neural tube defects.

Vitamin A is not safe and should be avoided in pregnancy due to chances for toxicity.

Vitamin C and iron are not considered as essential vitamins to be taken during pregnancy.

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.

HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.

Causes of Hyperprolactinemia: Prolactinomas, Medication (phenothiazines, metoclopramide, risperidone, selective serotonin reuptake inhibitors, oestrogens, verapamil), Stress, Pregnancy, Hypothyroidism, Kidney disease, Chest trauma

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

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.

Wound healing is initiated when inflammation begins. Macrophages predominate after neutrophils and peak 3-4 days after inflammation begins. They destroy and phagocytose the organism and debris using enzymes. The next step is the resolution of inflammation and healing of the wound.

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.

Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement.

The gestational sac can be visualized from as early as 4–5 weeks of gestation and the yolk sac at about 5 weeks (Figure 6.3). The embryo can be observed and measured at 5–6 weeks gestation.

Tetracycline is a broad-spectrum antibiotic that crosses placental barrier. Tetracycline was the first line of therapy in treating infections caused by Mycoplasma pneumoniae, chlamydia, rickettsia, and some spirochaetes. It has a wide range of adverse effects and is known for a unique property of being incorporated into skeletal and dental tissues at sites of active mineralization and staining of these tissues.

In the given case, the patient should be treated with Augmentin.
Asymptomatic bacteriuria occurs in about 2 % to 10 % of all pregnancies and if left untreated, about 30% of this will develop acute cystitis and the other 50% will develop acute pyelonephritis.

Escherichia coli is the most common pathogen associated with asymptomatic bacteriuria, which consists more than 80% of the isolate and Staphylococcus Saprophyticus accounts for about 5-10% of isolates associated with uncomplicated UTI. Escherichia coli is a very common normal flora found in the gastrointestinal tract and Staphylococcus Saprophyticus is a commonly found normal flora in genital tract and perineum.

Asymptomatic bacteriuria has found to be associated with low birth weight and preterm birth, and it is found that a short term antibiotic treatment will help in improving the fetal outcomes in cases of asymptomatic bacteriuria or uncomplicated UTI. Hence, all cases of asymptomatic bacteriuria and uncomplicated UTI during pregnancy are recommended to be treated with a five day course of oral antibiotics as this is normally sufficient in pregnant women.

Drug of choice in asymptomatic bacteriuria (directed therapy based on sensitivities) in case of E. coli are either:
– Cephalexin 500 mg oral twice a day for 5 days or
– Nitrofurantoin 100 mg orally twice daily for 5 days or
– Trimethoprim 300 mg oral doses daily for 5 days (avoided during first trimester and in those pregnant women with established folate deficiency, low dietary folate intake, or for women taking other folate antagonists).
– Amoxicillin + clavulanate 500 + 125 mg oral, twice daily for 5 days if < 20 weeks of gestation.
Note: In view of childhood outcomes – (ORACLE II trial and 7 year follow-up), which showed an associated increase in necrotising enterocolitis, functional impairment (low), and cerebral palsy, it is recommended that amoxicillin / clavulanate is only used if no alternative treatment is available(if >20 weeks of gestation).

Asymptomatic bacteriuria (directed therapy based on sensitivities ) in case of Staphylococcus saprophyticus infection is as follows:
Cephalexin 500 mg oral doses twice a day for 5 days or Amoxicillin 500mg TDS for 5 days.

Asymptomatic bacteriuria (directed therapy based on sensitivities) in case of infection with Pseudomonas suggest Norfloxacin 400 mg oral twice daily for 5 days, then repeat MSSU 48 hours after the treatment is completed.

In case of Group B streptococcus as a single organism, Penicillin V 500 mg oral twice daily for 5 days. If the patient is hypersensitive to penicillin give Cephalexin 500 mg orally twice a day for 5 days were immediate hypersensitivity is excluded. If immediate hypersensitivity to penicillin is noticed, then Clindamycin 450 mg three times daily for 5 days is advised.

Amoxicillin is found more effective in treating UTIs caused by organisms which are resistant to the drug in vitro because of its high concentrations attainable in urine. However, a study shows that amoxicillin-resistant organisms do not respond to amoxicillin alone but Augmentin [amoxicillin clavulanate] is found to cure urinary tract infection irrespective of the amoxicillin susceptibility of the organism in vitro. Of the patients infected with amoxicillin-resistant organisms, 80% were cured by augmentin and only 10% with infection by amoxicillin-resistant organisms were cured by amoxicillin.

Now a days Amoxicillin is not preferred as the common treatment option for UTI due to increasing incidences of Escherichia coli resistance, which accounts majority of uncomplicated urinary tract infections. Clavulanic acid which is a beta-lactamase inhibitor works synergistically with amoxicillin to extend spectrum antibiotic susceptibility. This makes UTIs less likely to be resistant to the treatment with amoxicillin clavulanate compared to amoxicillin alone.
Ciprofloxacin and Gentamicin which are the other antibiotic choice considered otherwise also should be avoided in pregnancy as they comes under FDA pregnancy Category C.