A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK.

A missed miscarriage is described as a loss of pregnancy without vaginal bleeding, loss of tissue, cervical changes or abdominal pain. During a scan, a fetal heartbeat is not observed, and the gestational sac may be small.

A threatened miscarriage is when the cervix dilates and uterine bleeding is seen; the pregnancy could still be viable. A complete miscarriage occurs when all the products of conception are expelled from the uterus, bleeding has stopped, and the cervix has closed up after dilation.

An inevitable miscarriage occurs with the usual symptoms of a miscarriage and a dilated cervix, suggesting that the passage of the fetal tissue is inevitable.

Recurrent miscarriages are described as spontaneous pregnancy loss of more than 2 to 3 consecutive times.

Condylomas are warty neoplasms of the vulvar area. The most common type are condyloma acuminatum which occur due to HPV 6 or 11. Condyloma latum are also known as secondary syphilis are less common. Both of these are sexually transmitted.

Stages of Syphilis:
– Primary 3-90 days
Chancre and lymphadenopathy
– Secondary 4-10 weeks
Widespread rash typically affecting hands and soles of feet.
Wart lesions (condyloma latum) of mucus membranes
– Latent Early <1 yr. after secondary stage
– Late >2 yr. after secondary stage
Asymptomatic
– Tertiary 3+ years after primary infection
Gummas or
Neurosyphilis or
Cardiovascular syphilis

There are several criteria that aid in the diagnosis of gestational diabetes in pregnancy including NICE, WHO and modified WHO:
GDM Diagnostic Criteria:
NICE: Immediate FBG >5.6, 2 hour glucose >7.8
WHO: Immediate FBG >6.1, 2 hour glucose >7.8
Modified WHO: Immediate FBG >7.1, 2 hour glucose >7.8

Random glucose and OGTT 2 hour readings of >11.1 are diagnostic of diabetes in non-pregnant states but are not part of the gestational diabetes criteria.

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

This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).

When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.

Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.

The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.

The vaginal epithelium is made of squamous cells. Hence the most common carcinoma that occurs in the Vagina is squamous cell carcinoma. Diagnosis is made with vaginal biopsy. Usually the pain only presents if the disease extends beyond the vagina involving the perineal nerves.

The following hormones are excreted from the anterior pituitary gland: TSH, GN, ACTH, LH, FSH, MSH, PRL.
Human chorionic gonadotropin (hCG, or human chorionic gonadotrophin) is a placental hormone secreted by syncitiotrophoblasts during the second week of gestation.

The pudenal nerves has three branches, namely the inferior rectal, perineal and the dorsal nerve of the clitoris. The perineal nerve has two branches: The superficial perineal nerve gives rise to posterior scrotal or labial (cutaneous) branches, and the deep perineal nerve supplies the muscles of the deep and superficial perineal pouches, the skin of the vestibule, and the mucosa of the inferior most part of the vagina. The inferior rectal nerve communicates with the posterior scrotal or labial and perineal nerves. The dorsal nerve of the penis or clitoris is the primary sensory nerve serving the male or female organ, especially the sensitive glans at the distal end.

Placental abruption is commonly defined as the premature separation of the placenta, which complicates approximately 1% of births. During the second half of pregnancy abruption is considered an important cause for vaginal bleeding and is mostly associated with significant perinatal mortality and morbidity.
Clinical presentation of abruption varies from asymptomatic cases to those complicated with fetal death and severe maternal morbidity. Classical symptoms of placental abruption are vaginal bleeding and abdominal pain, but at times severe cases might occur with neither or just of one of these signs. In some cases the amount of vaginal bleeding may not correlates with the degree of abruption, this is because the severity of symptoms is always depend on the location of abruption, whether it is revealed or concealed and the degree of abruption.
Diagnosis of abruption is clinical and the condition should be suspected in every women who presents with vaginal bleeding, abdominal pain or both, with a history of trauma, and in those women who present with an unexplained preterm labor. All causes of abdominal pain and bleeding, like placenta previa, appendicitis, urinary tract infections, preterm labor, fibroid degeneration, ovarian pathology and muscular pain are considered as differential diagnosis of abruption.

In the given case patient has developed signs and symptoms of placental abruption, like severe vaginal bleeding with abdominal pain, whose management depends on its presentation, gestational age and the degree of maternal and fetal compromise. As the presentation is widely variable, it is important to individualize the management on a case-by-case basis. More aggressive management is desirable in cases of severe abruption, which is not appropriate in milder cases of abruption. In cases of severe abruption with fetal death, as seen in the given case, it is reasonable to allow the patient to have a vaginal delivery,regardless of gestational age, as long as the mother is stable and there are no other contraindications.
The uterus is contracting vigorously, and labor occurs rapidly and progresses, so amniotomy is mostly sufficient to speed up delivery. There is a significant risk for coagulopathy and hypovolemic shock so intravenous access should be established with aggressive replacement of blood and coagulation factors. Meticulous attention should be paid to the amount of blood loss; general investigations like complete blood count, coagulation studies and type and crossmatch should be done and the blood bank should be informed of the potential for coagulopathy. A Foley catheter should be placed and an hourly urine output should be monitored.
It is prudent to involve an anesthesiologist in the patient’s care, because if labor does not progress rapidly as in cases like feto-pelvic disproportion, fetal malpresentation, or a prior classical cesarean delivery, it will be necessary to conduct a cesarean delivery to avoid worsening of the coagulopathy.
Bleeding from surgical incisions in the presence of DIC may be difficult to control, and it is equally important to stabilize the patient and to correct any coagulation derangement occuring during surgery. The patient should be monitored closely after delivery, with particular attention paid to her vital signs, amount of blood loss, and urine output. In addition, the uterus should be observed closely to ensure that it remains contracted and is not increasing in size.
Immediate delivery is indicated in cases of abruption at term or near term with a live fetus. In such cases the main question is whether vaginal delivery can be achieved without fetal or maternal death or severe morbidity. In cases where there is evidence of fetal compromise, delivery is not imminent and cesarean delivery should be performed promptly, because total placental detachment could occur without warning.

During the ovulatory cycle, only one follicle will ovulate. The remaining non-ovulating follicles undergo disintegration. This process is known as atresia.

The transabdominal ultrasound uses a frequency of 3.5-7 MHz emitted from a transducer. Transvaginal 5-7.5 MHz (post bladder void.

Congenital cytomegalovirus infections are the most common cause of sensorineural hearing loss in babies. Cytomegalovirus infection during the perinatal period can be transferred to the foetus especially if the primary infection is during pregnancy. In babies born with congenital CMV about 10-15% are symptomatic, while 10-15% of those who are asymptomatic will develop symptoms in life. Some of the features of CMV infection include sensorineural hearing loss, visual impairment, cerebral palsy, microcephaly and seizures. Other causes of infective congenital sensorineural hearing loss include: Rubella, HIV, Herpes Simplex Virus, Measles, Varicella Zoster virus, Mumps and West Nile Virus.

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

Uterine atony is the most common cause for postpartum haemorrhage and the conditions like multiple pregnancy, polyhydramnions, macrosomia, prolonged labour and multiparity are the most common risk factor for uterine atony.

Whereas less common causes for postpartum haemorrhage are laceration of genital tract, uterine rupture, uterine inversion and coagulopathy.

Prothrombin time is increased in:
– Factor V deficiency
– Vitamin K deficiency (which affects factors 2,7 and 10)
– Warfarin therapy
– Severe liver failure
Protein C is an anticoagulant and deficiency results in a hyper-coagulable state with tendency towards thrombosis.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

Prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in preparation for the production of milk. However, milk is not secreted then, because progesterone and oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.

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.

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

There is 70% chance that a women who has had a C-section can deliver via spontaneous vaginal delivery.

The two main cell types of the ovaries:
1. The theca cells produce androgen in the form of androstenedione. The theca cells are not able to convert androgen to oestradiol themselves. The produced androgen is therefore taken up by granulosa cells.
2. The neighbouring granulosa cells then convert the androgen into oestradiol under the enzymatic action of aromatase FSH induces the granulosa cells to produce aromatase for this purpose

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

The cardiotocograph (CTG) is a continuous tracing of the fetal heart rate used to assess fetal wellbeing. The Doppler effect detects fetal heart motion and allows the interval between successive beats to be measured, thereby allowing a continuous assessment of fetal heart rate. The mother perceives the fetal movement by the 18-20 week of gestation and these increase until the 32 week. A mother should under go CTG if the fetal movements are reduced by the 28 week of gestation.

(13-20 weeks). If a mother has chickenpox in late pregnancy (5 days prior to delivery) then there is risk of neonatal varicella infection which may be severe.

The condition should be an X-linked recessive condition, as it affects only male offspring. Duchene muscular dystrophy is an X-linked recessive condition. Cystic fibrosis is an autosomal recessive disorder. Spina bifida is a multifactorial condition. Down syndrome is caused by trisomy of chromosome 21. Spinal muscular atrophies are inherited in an autosomal-recessive pattern.

The given case scenario describes a typical case of measles in a pregnant woman, which is confirmed by serologic studies. Positive lgM in serology is suggestive of acute infection, while a negative lgG confirms that the infection is in early phase without any seroconversion.
Conservative management of the symptoms and its potential complications is the only management plan therapeutically available after contracting measles. ‘Notification’ and contact tracing are the other very important issues to be considered.
Measles is a notifiable disease and healthcare professionals are mandated on reporting all the identified cases of measles to the authorized public health units. The main objective of this notification is to conduct a contact tracing.

MMR vaccine is not useful once measles is contracted, as the vaccine is used for prevention of measles and as prophylaxis in post-exposure cases. For those with contact to a case of measles, MMR vaccine within 72 hours of contact may have a protective effect, but all measles-containing vaccines like MMR and MM RV are contraindicated throughout pregnancy even as prophylaxis.

As the circulating maternal antibodies will cross placenta and enters into the fetal circulation, a positive test does not confirm infection in the fetus. So serologic testing of the fetus is not useful.

NHIG is not useful in treating an established case of measles, as it is used as a post-measles exposure prophylactic for patients such as pregnant women, premature babies, etc who are contraindicated to MMR vaccine.

As both symptoms and lgM levels indicate measles infection, repeating measles-specific serologic test is not useful in this case. In general no test is indicated, unless its result has an impact on the further management of the case or any prognostic value.

Nutrition in pregnancy
Weight gain must be:
– In patients <18.5 kg/m2, there should be an increase of 12.7 - 18 kg (28-40 lb)
– In patients 18.5 – 24.9 kg/m2 there should be an increase of 11.4 – 15.9 kg (25-35 lb)
– In patients 25 – 29.9 kg/m2 there should be an increase of 6.8 – 11.4 kg (15-25 lb)
– In patients ≥30 kg/m2 there should be an increase of 5 – 9 kg (11-20 lb)

Supplementation required:
– Intake of daily prenatal vitamin
– Additional specific supplements as indicated
– Avoidance of harmful substances like drugs, alcohol, etc
– Substance abuse counseling
– Avoidance of fish with high mercury levels
– Moderating caffeine intake

Food safety:
– Avoid undercooked meat, fish & eggs
– Clean raw fruits & vegetables before consuming
– Avoid unpasteurized dairy products

Nutrition in pregnancy is addressed at the initial prenatal visit based on pre-pregnancy BMI. Appropriate weight gain for a women with a normal pre-pregnancy BMI of 18.5 – 24.9 kg/m2 should be 11.4 – 15.9 kg (25-35 lb) during pregnancy. This weight gain is equivalent to the increasing caloric intake of 350 kcal/day during the second and 450 kcal/day during the third trimesters.  Patients following any specific diets like veganism can continue their usual diet throughout pregnancy as long as it contains a well-balanced quantity of protein, carbohydrates and fats.

Vitamin and mineral supplementation during pregnancy is a single, daily prenatal vitamin recommended for majority of pregnant women as it helps to fulfill most of the daily vitamin and mineral supplementation requirements. In case of patients with vitamin or mineral deficiencies like iron, calcium, etc, a specific supplementation of the deficit vitamin/mineral only is required rather than multiple prenatal vitamins to avoid consuming harmful amounts of other vitamins like vitamin A.  Vegans, who are at risk for some vitamin and mineral deficiencies like vitamin B12, calcium, iron, etc, secondary to lack of meat consumption, may require supplementation.

Pregnant women are counselled on avoidance of harmful substances like alcohol, drugs, etc and substances like fish with high mercury levels.  Although high caffeine intake during pregnancy can be harmful, a moderate intake ie, 1 or 2 cups of coffee a day is thought to be safe.

Safe handling of food is important because some food products are found to result in congenital infection and intrauterine fetal demise. Patients are also counselled to avoid undercooked meat, fish, and eggs; to thoroughly clean raw fruits and vegetables and to avoid consumption of unpasteurized dairy products.

By maintaining a proper maternal nutrition during pregnancy, patients are provide appropriate nutrition to the fetal and thereby reducing the risk of pregnancy related complications like low birth weight, preterm delivery, etc.

Pregnant patients are counseled to avoid exercises like contact sports, downhill skiing, etc which increases the risk of abdominal trauma resulting in increased risk of placental abruption. But those patients with an uncomplicated pregnancy, who are already accustomed with long-duration, high-intensity exercise like running 5 miles/day, as in the given case, can continue with their regimen if tolerated.

Proper nutrition in pregnancy includes appropriate weight gain, supplementation of vitamins and minerals, avoidance of any harmful substances, and safe handling of food. Patients with a normal pre-pregnancy BMI should gain around 11.4-15.9 kg (25-35 lb) during pregnancy by increasing their caloric intake by 350 kcal/day in the second and 450 kcal/day in the third trimesters.

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.

During fertilization, a sperm must first fuse with the plasma membrane and then penetrate the female egg cell to fertilize it. Fusing to the egg cell usually causes little problem, whereas penetrating through the egg’s hard shell or extracellular matrix can be more difficult. Therefore, sperm cells go through a process known as the acrosome reaction, which is the reaction that occurs in the acrosome of the sperm as it approaches the egg. The acrosome is a cap-like structure over the anterior half of the sperm’s head. Upon penetration, if all is normally occurring, the process of egg-activation occurs, and the oocyte is said to have become activated. This is thought to be induced by a specific protein phospholipase c zeta. It undergoes its secondary meiotic division, and the two haploid nuclei (paternal and maternal) fuse to form a zygote. To prevent polyspermy and minimize the possibility of producing a triploid zygote, several changes to the egg’s cell membranes render them impenetrable shortly after the first sperm enters the egg.

Congenital rubella infection that occurs after 16 weeks gestation does not typically cause fetal abnormalities. This however plays no part in vaccination advice. Rubella vaccine is live and should not be given during pregnancy. The mother should be offered vaccination after giving birth. It is safe for the vaccine (typically given as combined MMR) to be administered if the mother is breastfeeding.