The properties of oestrogen:
Structure: Stimulates endometrial growth, maintenance of vessels and skin,
reduces bone resorption, increases bone formation, increases uterine growth
Protein synthesis: Increases hepatic synthesis of binding proteins
Coagulation: Increases circulating levels of factors II, VII, IX, X, antithrombin III and plasminogen; increases platelet adhesiveness
Lipid: Increases HDL and reduces LDL,increases triglycerides, reduces
ketone formation, increases fat deposition
Fluid balance: Salt and water retention
Gastrointestinal: Reduces bowel motility, increases cholesterol in bile

RNA viruses are almost always single stranded whilst DNA viruses are almost always double stranded. The exceptions are rotavirus and Parvovirus B19 respectively.

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.

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.

It is stage 2 of the disease.

Staging:
1 Confined to uterus
1A < 50% myometrial invasion
1B > 50% myometrial invasion
2 Cervical stromal invasion but not beyond uterus
3 Extension beyond the uterus
3A Tumour invades the serosa or adnexa
3B Vaginal and/or parametrial invasion
3C1 Pelvic nodal involvement
3C2 Para aortic nodal involvement
4 Distant Metastasis
4A Tumour invasion of the bladder and/or bowel mucosa
4B Distant metastases including abdominal metastases and/or inguinal lymph nodes

When cervical biopsy or colposcopy doesn’t explain the severity of the pap smear results cone biopsy is done. In 10% of biopsies, results will be different from that of the pap smear as in this patient with pap smear showing HSIL and colposcopy showing chronic cervicitis.

In such cases conization is indicated. Repeating the pap smear could risk prompt management of a serious problem. No destructive procedure, ablation or cryotherapy, should be done before diagnosis is certain.

Macrophages are derived from monocytes. When monocytes come across a pathogen they differentiate into macrophages for phagocytosis to occur.

Listeria Monocytogenes is a cause of congenital infection. The most common source of the bacteria is food, especially unpasteurised milk. Congenital listeriosis can lead to spontaneous abortions, premature birth and chorioamnionitis. At birth, neonates may present with septicaemia, respiratory distress and inflammatory granulomatosis. The case mortality rate for listeriosis is thought to be between 20-30%.

Most common risk factors for spontaneous abortion are considered to be:
– Age above 35 years.
– Smoking.
– High intake of caffeine.
– Uterine abnormalities like leiomyoma, adhesions.
– Viral infections.
– Thrombophilia.
– Chromosomal abnormalities.
Conditions like subclinical thyroid disorder, subclinical diabetes mellitus and retroverted uterus are not found to cause spontaneous abortions.
The term retroverted uterus is used to denote a uterus that is tilted backwards instead of forwards.

Squamous cell carcinoma is the most common type of vaginal cancer.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a nonstress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

The use of long-acting reversible contraceptives (LARCs) is globally accepted as a strategy that is successful in decreasing rates of unintended pregnancy, especially in very young women.
Long-acting reversible contraceptives (LARCs) are defined as any contraceptive that requires administration less than once per cycle (i.e. per month). This includes copper and progestogen-only intrauterine devices (IUDs), and progestogen subdermal implants and injections. However, subdermal implants and IUDs, which have a life of at least three years, have superior efficacy over injections, which require administration every three months. Implants and IUDs are highly cost-effective when compared with other contraceptive methods.

LARCs are widely recommended by professional bodies and the World Health Organization (WHO) as first-line contraception for young women as they are safe, effective and reversible. Young women should be offered the choice of a LARC as part of a fully informed decision for their first form of contraception.

LARCs surpass barrier methods and contraceptive pills in effectiveness and safety therefore all other options are incorrect.

Fat necrosis may occur following a traumatic injury to the breast. The lump is usually firm, round, and painless.

The normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.

Neisseria Gonorrhoeae is a Gram negative diplococci.

The bony pelvis is made up of a girdle with a central canal. The rim that surrounds the upper opening of the canal is called the pelvic inlet, while the lower rim is the called the pelvic outlet. The pelvic outlet is diamond-shaped and is bounded posteriorly by the tip of the sacrum, and anteriorly by the pubic symphysis, with its lateral boundaries being the ischial tuberosities and the sacrotuberous ligament.

Absolute contraindications to OCs include breast cancer, history of deep venous thrombosis or pulmonary embolism, active liver disease, use of rifampicin, familial hyperlipidaemia, previous arterial thrombosis, and pregnancy, while relative contraindications include smoking, age over 35, hypertension, breastfeeding, and irregular spontaneous menstruation.

Progestin only pills are the safest and most effective contraceptive methods than the rest of the options.

Literature review shows that bicornuate uterus is associated with increase risk of spontaneous abortion in about 36% of patients. There is also an increased risk of preterm birth, malpresentation and fetal growth retardation.

The risk of developing endometrial carcinoma is less than 5% over 20 years if the endometrium shows hyperplasia without atypia.
There are 2 types of Endometrial Hyperplasia:
1. Hyperplasia without atypia*
2. Atypical hyperplasia

Major Risk Factors:
Oestrogen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant)

The bladder is supplied by branches of the internal iliac artery, including the superior vesical artery, branches of the gluteal and obturator arteries and the inferior vesical artery in males and the vaginal and the uterine arteries in females.

A cephalic presentation is the one where head of the foetus enters the pelvic cavity at the time of delivery. The commonest form of cephalic presentation is the vertex presentation in which the occiput of the foetus enters the birth canal.

In patients with normal BMI there is no preferential entry method. The Varess technique is not appropriate for morbidly obese or very thin patients for the reasons set out below: Morbid Obesity (BMI>40): Hasson technique or entry at Palmers point Reason: difficult penetration with Varess needle Very Thin Patients: Hasson technique or insertion at Palmers point Reason: higher risk of vascular injury

The fetal head is engaged when the head of the foetus or the presenting part enters the pelvic inlet or pelvic brim. It usually occurs at 38 weeks of gestation.
The Spalding sign refers to the overlapping of the fetal skull bones caused by collapse of the fetal brain. It appears usually a week or more after fetal death in utero.
In brow presentation the scalp is deflexed as the foetus is looking upward. Normally the head is inflexed such that the chin is touching the chest.

Vulva is defined by the area which is located outside the female vagina and comprises of the labia majora, labia minora, clitoris, mons pubis and Bartholin glands. It is supplied by the vestibula branch of pudental artery.
Inferior hemorrhoidal artery supplies the lower part of the rectum.
Femoral artery is the continuation of external iliac artery and supplies most of the leg.

Hereditary breast cancers account for 10 % of the cases. BRCA gene mutations account for 25 % of these cancers.

If the external anal sphincter is in tact then this is a 1st or 2nd degree tear. As the perineal muscles are involved this is 2nd degree tear.

Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. 

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.

Lymphatic vessels from the vagina drain from the parts of the vagina as follows:
• Superior part: to the internal and external iliac lymph nodes.
• Middle part: to the internal iliac lymph nodes.
• Inferior part: to the sacral and common iliac nodes.

The levels of oestradiol (E2), progesterone, and prolactin (PRL) are all elevated during early pregnancy. However these elevations cannot be solely relied on to determine if pregnancy has occurred since increased levels of these hormones can also occur in pathologic states in non-pregnant women or, in some cases, even during menstrual cycles.

The levels of follicle stimulating hormone (FSH) are suppressed in pregnancy because of the elevated E2 and progesterone levels.

The correct answer is elevated levels of luteinising hormone (LH). This is because the beta sub-units of LH and human chorionic gonadotrophin (hCG) are almost identical and therefore, hCG is measured as LH in almost all LH assays (correct answer).

The LH levels can be slightly raised in polycystic ovarian syndrome; however, it is unlikely that the levels would increase above 30 mIU/mL in this condition.

The mid-cycle levels of LH can go up to 100-150 mIU/mL. If the levels are more than 200 mlU/mL, it usually indicates pregnancy.