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.

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.

Free T3 (FT3) and free T4 (FT4) levels are slightly lower in the second and third trimesters. Thyroid-stimulating hormone (TSH) levels are low-normal in the first trimester, with normalization by the second trimester.

Taking hormone replacement therapy for more than 5 years can increase the risk of developing breast cancer. HRT is not recommended as treatment for osteoporosis alone in postmenopausal women older than 60. Raloxifene reduces risk of vertebral fracture in post menopausal women.

Fetal lie refers to the relationship between the long axis of the foetus relative to the long axis of the mother. If the foetus and maternal column are parallel (on the same long axis), the lie is termed vertical or longitudinal lie.

Fetal presentation means, the part of the foetus which is overlying the maternal pelvic inlet.

Position is the positioning of the body of a prenatal foetus in the uterus. It will change as the foetus develops. This is a description of the relation of the presenting part of the foetus to the maternal pelvis. In the case of a longitudinal lie with a vertex presentation, the occiput of the fetal calvarium is the landmark used to describe the position. When the occiput is facing the maternal pubic symphysis, the position is termed direct occiput anterior.

Fetal attitude is defined as the relation of the various parts of the foetus to each other. In the normal attitude, the foetus is in universal flexion. The anatomic explanation for this posture is that it enables the foetus to occupy the least amount of space in the intrauterine cavity. The fetal attitude is extremely difficult, if not impossible, to assess without the help of an ultrasound examination.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

Fibroids are a common gynaecological condition found in many women above the age of 35. They are however uncommon before puberty. They are most common in black women vs white women, and its prevalence increases from puberty to menopause. Risk factors for fibroids include increasing age, obesity and infertility. Protective factors, on the other hand, include pregnancy, as the risk of fibroids decreases with increasing numbers of pregnancies.

Fetal heart rate tracings (FHR) under category I include all of the following:
– baseline rate 110– 160 bpm
– baseline FHR variability moderate
– accelerations present or absent
– late or variable decelerations absent
– early decelerations present or absent

The onset of fetal bleeding is marked by a tachycardia followed by a bradycardia with intermittent accelerations or decelerations. Small amounts of vaginal bleeding associated with FHR abnormalities should raise the suspicion of fetal haemorrhage. This condition demands prompt delivery and immediate reexpansion of the neonatal blood volume.

The perineal membrane (also known as the inferior fascia of the urogenital diaphragm) separates the deep and superficial perineal pouches i.e. it is the inferior border of the deep pouch and superior border of the superficial pouch. The deep perineal pouch is the space therefore between superior and inferior layers of the urogenital diaphragm The superior fascia of the urogenital diaphragm is the superior border

Pre-eclampsia presents with other features in addition to the presence of hypertension, also it’s diagnosis cannot be made considered peripheral edema as the only presenting symptom. Proteinuria occurs more commonly in pre-eclampsia than in gestational hypertension and the latter is mostly asymptomatic.

Hypertensive disorders are found to complicate about 10% of all pregnancies. Common one among them is Gestational hypertension, which is defined as the new onset of hypertension after 20 weeks of gestation without any maternal or fetal features of pre-eclampsia, in this case BP will return to normal within three months of postpartum.

Types of hypertensive disorders during pregnancy:
1. Pregnancy-induced hypertension:
a. Systolic blood pressure (SBP) above 140 mm of Hg and diastolic hypertension above 90 mmHg occurring for the first time after the 20th week of pregnancy, which regresses postpartum.
b. The rise in systolic blood pressure above 25 mm of Hg or diastolic blood pressure above 15 mm of Hg from readings before pregnancy or in the first trimester.
2. Mild pre-eclampsia:
BP up to 170/110 mm of Hg in the absence of associated features.
3. Severe pre-eclampsia:
BP above 170/110 mm of Hg and along with features such as kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise.
4. Essential (coincidental) hypertension:
Chronic underlying hypertension occurring before the onset of pregnancy or persisting after postpartum.
5. Pregnancy-aggravated hypertension:
Underlying hypertension which is worsened by pregnancy.

To diagnose pre-eclampsia clinically, presence of one or more of the following symptoms are required along with a history of onset of hypertension after 20 weeks of gestation.
– Proteinuria: Above 300 mg/24 h or urine protein
reatinine ratio more than 30 mg/mmol.
– Renal insufficiency: serum/plasma creatinine above 0.09 mmol/L or oliguria.
– Liver disease: raised serum transaminases and severe epigastric or right upper quadrant pain.
– Neurological problems: convulsions (eclampsia); hyperreflexia with clonus; severe headaches with hyperreflexia; persistent visual disturbances (scotomata).
– Haematological disturbances like thrombocytopenia; disseminated intravascular coagulation; hemolysis.

Spinnability (or Spinnbarkeit), which measures the capacity of fluids to be drawn into threads, represents an indirect measurement of the adhesive and elastic properties of mucus.

During pregnancy, the chances for a woman to develop oral candidiasis double. An aphthous ulcer has a yellowish floor which is surrounded by an erythematous halo while in lichen planus, the lesions do not have the appearance of a thick white mark but are more or less lace-like. The lesions in leucoplakia have raised edges and they appear as bright white patches which are sharply defined and cannot be rubbed out. Smoking may affect the tongue, producing tongue coating. In this case the tongue is just inflamed which is a sign of infection.

AFP is a glycoprotein that is synthesized in the fetal liver (primarily), umbilical vesicles and the gut. It is found in elevated quantities in the fetal serum and peaks at around 14 week of gestation.

The common route of metastases of the ovarian cancer is transcoelomic route.

In the management of a miscarriage, after the completion of 7-14 days of expectant management, the woman is advised to take a pregnancy test after 3 weeks. In case of a positive result she is to return for further care.

The cardinal ligament (or Mackenrodt’s ligament, lateral or transverse cervical ligament) is a major ligament of the uterus. It is located at the base of the broad ligament of the uterus. It attaches the cervix to the lateral pelvic wall by its attachment to the Obturator fascia of the Obturator internus muscle, and is continuous externally with the fibrous tissue that surrounds the pelvic blood vessels. It thus provides support to the uterus.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. There are various risk factors for gestational diabetes including increasing age, ethnicity, previous still births etc.

Among a variety of imaging modalities developed for breast cancer screening, mammography is the best-studied and the only imaging technique that has been shown to decrease mortality as demonstrated in multiple randomized trials. However, it is important to know that, even in the best circumstances, mammography may miss up to 20 percent of underlying breast cancers.

Women on HRT are likely to have dense breast. Dense breasts are associated with an increased risk of breast cancer and can decrease the sensitivity of mammography for small lesions. Nevertheless, we do not alter our general approach to age- and risk-based screening based on breast density. However, for women with dense breasts, we do prefer digital mammography over film mammography, due to greater sensitivity; digital mammography is the modality typically used for mammography in most locations in the United States.

This patient has experienced polycystic ovarian syndrome-like symptoms.
At least two out of three of the following criteria must be met to diagnose polycystic ovarian syndrome:
1- Hyperandrogenism suggesting an excess of androgens e.g. excess hair growth, acne etc.
2- Menstrual irregularities e.g. dysmenorrhea, oligomenorrhea, and amenorrhea.
3-The ovaries are polycystic if one ovary has 12 or more follicles or if the size of one or both ovaries has risen.

Low FSH, LH, and pituitary hormones are typically associated with hypothalamic dysfunction, however this is not the case here.
Similarly, with premature ovarian failure, FSH/LH levels rise while oestrogen levels decrease.

All of the other choices are incorrect.

The most common treatment approach is with the dopamine receptor agonists, bromocriptine, and cabergoline. Bromocriptine normalizes prolactin and decreases tumour size in 80%–90% of patients with microadenomas. Bromocriptine should be given to this patient who has developed hyperprolactinemia anovulation.

Women with hyperprolactinaemic anovulation are treated with dopamine agonists such as bromocriptine.
This patient has also developed symptoms of a low-functioning pituitary gland tumour, which bromocriptine will assist to shrink. Before starting bromocriptine, a head MRI scan should be considered to confirm the suspected diagnosis.

Clomiphene is an oestrogen receptor modulator that is selective. It works by competing with oestrogen receptors in the hypothalamus. This disrupts normal negative feedback mechanisms, causing the release of pituitary gonadotropins, particularly LH, to rise, triggering ovulation.
When the levels of gonadotropins and oestrogen are normal but the women still have ovulatory dysfunction, it is successful in inducing ovulation. In hypogonadotropic hypogonadism and hypogonadotropic hypogonadism patients, clomiphene is frequently ineffective.

The treatment of asphyxia starts with the correct perinatal management of high-risk pregnancies. The management of the hypoxic-ischemic new-borns in the delivery room is the second fundamental step of the treatment. Low Apgar scores and need for cardiopulmonary resuscitation at birth are common but nonspecific findings. Most new-borns respond rapidly to resuscitation and make a full recovery. The outcomes for new-borns who do not respond to resuscitation by 10 minutes of age are very poor, with a very low probability of surviving without severe disability. Resuscitation in room air is advised for term new-borns, since the use of 100% oxygen is associated with worse outcomes compared to the use of room air.

This patient has developed symptoms of ovulation discomfort, which is also known as Mittelschmerz syndrome. Lower abdominal and pelvic pain that arises around the middle of a woman’s menstrual cycle characterises this condition.
The discomfort usually appears suddenly and disappears within hours, though it can continue up to three days.

The symptoms of ovulation pain can include:
– Lower abdomen pain.
– The pain typically occurs about two weeks before the menstrual period is due.
– The pain is felt on the right or left side, depending on which ovary is releasing an egg.
– The pain may switch from one side to the other from one cycle to the next, or remain on one side for a few cycles.
The duration of pain ranges anywhere from minutes to 48 hours.

Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.

With increasing maternal age, the risk of miscarriage increases. For women between the ages of 40-44, the miscarriage rates sit at about 50% and increases to over 75% for women 45 years and over. The miscarriage rate for women between the ages of 35-39 is 25%.

Shortly after the Morula enters into the uterus, approximately on the 4th day after fertilization a fluid filled cystic cavity appears in the morula and transforms the morula into a blastocyst.

The round ligament develops from the lower end of the gubernaculum in females. In the males it persists as the scrotal ligament.

The clinical evaluation indicates that the patient is ovulating but has not started menstruating. These observations suggest that the pain she is experiencing on a monthly basis could be related to ovulation or there could be an obstruction preventing the flow of menstrual blood from the uterus.

Uterine or vaginal anomalies that can obstruct menstrual flow include imperforate hymen, absent vagina, a transverse vaginal septum, or cervical obstruction.

If the cause was an obstruction to the flow, the retained menstrual products would have developed into a suprapubic mass (hematometra/ haematocolpos). However, no palpable mass was detected on abdominal examination.

Mullerian (paramesonephric) agenesis (correct answer) is the only condition that would result in no endometrial development; consequently there was no palpable mass observed and no menstrual loss that could be shed was present. A pelvic (lower abdominal) ultrasound examination can confirm the diagnosis.

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

In a person who is infected by streptococcus (Group B) should be started on benzylpenicillin as soon as possible. In case of allergy vancomycin should be started at 1g every 12 hours. Tetracyclines should be avoided in pregnancy.

Combined oral contraceptive pills (COCPs) can be started immediately following abortion or miscarriage. Note following childbirth COCPs should not be restarted for 3 weeks (assuming the patient is not breastfeeding).