According to NICE guidelines women with type I diabetes, who are expecting a child should aim to keep their HbA1c level[1] below 48 mmol/mol (6.5%) without causing problematic hypoglycaemia. Women with diabetes whose HbA1c level is above 86 mmol/mol (10%) should be strongly advised not to get pregnant because of the associated risks. The risks are higher with chronic diabetes. There is an increased risk to the foetus or mother due to diabetes in pregnancy. Women who are waiting to become pregnant should take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.

Randomized control trials are the gold standard when it comes to assessing the treatment options or interventions in medicine. Since its introduction, RCT has questioned the validity of treatments such as oral hypoglycaemic agents, myocardial infarction hospitalization, varicose veins, toxicity and applicability of many preventive and therapeutic procedures. The basic steps include drawing up the protocol, selecting a study population, randomization, intervention, follow up and assessment of the outcome. Note if assessing prognosis or diagnostic tests Cohort and Cross Sectional Analysis are best.

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.

Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.

Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.

BV recurrence rates are high, approximately 80% three months after effective treatment.

Female infants are thought to be born with the total number of gametes they will posses in their lifetime. About 1 million healthy oocytes are present at birth. However, only about 300,000 of these oocytes survive to puberty, a number which continues to decline until all the oocytes are depleted triggering menopause.

In premenopausal women, watchful waiting usually involves monitoring for symptoms (pelvic pain or pressure) and repeating the pelvic ultrasound after six to eight weeks. If the ovarian cyst does not enlarge or if it resolves during the period of watchful waiting, it does not usually require surgical removal. Some premenopausal women will be advised to take a birth control pill during this time to help prevent new ovarian cysts from developing.

If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until your healthcare provider is certain that the cyst is not growing. If the cyst resolves, no further testing or follow-up is required.
Surgery may be recommended in the following situations:
– A cyst is causing persistent pain or pressure, or may rupture or twist.
– A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
– Large cysts (>5 to 10 cm) are more likely to require surgical removal compared to smaller cysts. However, a large size does not predict whether a cyst is cancerous.
– If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies, your healthcare provider may recommend surgery.
– If the suspicion for ovarian cancer is low but the cyst does not resolve after several ultrasounds, you may choose to have it removed after a discussion with your healthcare provider. However, surgical removal is not usually necessary in this case.

Vulval intraepithelial neoplasia is a premalignant condition which is associated with HPV or lichen sclerosis. Biopsy is essential for diagnosis. Treatment depends of the patients choice and include surgical excision of the area or laser therapy with CO2. Other treatment modalities include immunomodulating creams.

The 3rd arch gives rise to the Glossopharyngeal nerve.

Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.

Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).

Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.

Corpus albicans is the regressed form of the corpus leuteum. It is formed when the corpus leuteum is engulfed by macrophages and a scar or fibrous tissue is formed, called the corpus albicans.

The ovarian artery is an artery that supplies oxygenated blood to the ovary in females. It arises from the abdominal aorta below the renal artery. It can be found in the suspensory ligament of the ovary, anterior to the ovarian vein and ureter.

Station 0 – This is when the baby’s head is even with the ischial spines. The baby is said to be engaged when the largest part of the head has entered the pelvis.
If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

Toxoplasma gondii is a protozoan parasite found in cat faeces, soil or uncooked meat. Infection occurs by ingestion of the parasite from undercooked meat or from unwashed hands. Spiramycin treatment can be used in pregnancy (a 3-week course of 2–3 g per day). This reduces the incidence of transplacental infection but has not been shown to definitively reduce the incidence of clinical congenital disease. If toxoplasmosis is found to be the cause of abnormalities detected on ultrasound scan of the foetus, then termination of pregnancy can be offered.

This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes haemoglobin, haematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid- A peripheral smear and coagulation profiles also may be obtained- Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

→ Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
→ It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
→ Delivery is the definitive treatment for preeclampsia- The timing of delivery is determined by the gestational age of the foetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over caesarean delivery, if possible, in patients with preeclampsia.

Ovulation usually occurs on day 14 in a typical 28-day cycle. Luteinizing hormone levels spike as a result of increased oestrogen levels secreted from maturing follicles. This LH spike occurs about 24-36 hours before the release of the oocyte from the mature follicle.

The CDC recommends that:
If diarrhoea occurs within 24 hours of taking oral birth control or continues for 24 to 48 hours after taking a pill, an additional dose is not needed.
If diarrhoea lasts more than 48 hours Use backup birth control, such as condoms, or avoid sexual intercourse until pills have been taken for seven diarrhoea-free days.

All other options are incorrect.

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.

Spontaneous abortion is the loss of pregnancy naturally before twenty weeks of gestation. Colloquially, spontaneous abortion is referred to as a ‘miscarriage’ to avoid association with induced abortion. Early pregnancy loss refers only to spontaneous abortion in the first trimester. In 50% of cases, early pregnancy loss is believed to be due to fetal chromosomal abnormalities. Advanced maternal age and previous early pregnancy loss are the most common risk factors. For example, the incidence of early pregnancy loss in women 20-30 years of age is only 9 to 17%, while the incidence at 45 years of maternal age is 80%. Other risk factors include alcohol consumption, smoking, and cocaine use.

Several chronic diseases can precipitate spontaneous abortion, including diabetes, celiac disease, and autoimmune conditions, particularly anti-phospholipid antibody syndrome. Rapid conception after delivery and infections, such as cervicitis, vaginitis, HIV infection, syphilis, and malaria, are also common risk factors. Another important risk factor is exposure to environmental contaminants, including arsenic, lead, and organic solvents. Finally, structural uterine abnormalities, such as congenital anomalies, leiomyoma, and intrauterine adhesions, have been shown to increase the risk of spontaneous abortion.

Treatment with Clomiphene should not exceed 6 months.

Patient mentioned in the case has developed severe nausea and vomiting at the initial weeks of pregnancy. If the following clinical features are present, it confirms the diagnosis of hyperemesis gravidarum:
– Weight loss of more than 5% of pre-pregnancy weight
– Moderate to severe dehydration.
– Ketosis
– Electrolyte abnormalities.

Management of hyperemesis gravidarum include:
– Temporary suspension of oral intake, followed by gradual resumption.
– Intravenous fluid resuscitation, beginning with 2 L of Ringer’s lactate infused over 3 hours to maintain a urine output of more than 100 mL/h.
– Use of Antiemetics like metoclopramide, if needed.
– Oral administration of Vitamin B6.
– Replacement of electrolytes if required in the case.

Encouraging oral intake and sending this patient home without any intravenous hydration, is not considered the correct treatment option in this case.

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

Reduced fetal movements can be the first indication of possible fetal abnormalities. Movements are first perceived by the mother from about 18-20 weeks gestation, increase in size and frequency until 32 weeks gestation when they plateau at about 31 movements per hour. Investigations for reduced fetal heart rate include auscultation of the fetal heart rate using a handheld doppler device, and a cardiotocograph or ultrasound if the foetus is above 28 weeks gestation. About 70% of women who experience one episode of reduced fetal movement have uncomplicated pregnancies. They are advised to report to a maternal unit if another episode occurs.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

This is typical appearance of molar pregnancy. This used to be referred to as ‘snowstorm sign’ as with older poorer resolution ultrasound the anechoic species looked like a snowstorm.

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

The placenta produces Estriol from 16-OH DHEAS. Estriol is the major oestrogen (oestrogen) of pregnancy and the placenta is the primary site of production. Pregnenolone is synthesised by the placenta from cholesterol and this is converted to dehydroepiandrosterone (DHEA) in the fetal adrenal gland

Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood. The uterus is 50–60 g prior to pregnancy and 1000 g by term. The volume increases from 10 ml to 5000ml approx. It is around 40g at menopause.

Folic Acid should be increased in diet of a pregnant women. Deficiency will lead to neural tube defects i.e. spina bifida.

It is stage 2B. Stage I: is strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion.
2010 FIGO classification of cervical carcinoma:
Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.

Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
Stage IB1: Clinical lesions no greater than 4 cm in size.
Stage IB2: Clinical lesions greater than 4 cm in size.

Stage II: carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall.

Stage III: carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.

Stage IV: carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.
Stage IVA: Spread of the tumour into adjacent pelvic organs.
Stage IVB: Spread to distant organs.

The normal fetal heart rate ranges from 120-160 beats per minute in the uterine period.

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.