The occurrence of migraine in women is influenced by hormonal changes throughout the lifecycle. A beneficial effect of pregnancy on migraine, mainly during the last 2 trimesters, has been observed in 55 to 90% of women who are pregnant, irrespective of the type of migraine.

For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) preferably as a suppository is considered the first choice drug treatment. The risks associated with use of aspirin (acetylsalicylic acid) and ibuprofen are considered to be small when the agents are taken episodically and if they are avoided during the last trimester of pregnancy.

Paracetamol 500 mg alone or in combination with metoclopramide 10 mg are recommended as first choice symptomatic treatment of a moderate-to-severe primary headache during pregnancy.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 week old and is replaced by adult haemoglobin by the age of 5 months post natally. Only 2% of the haemoglobin is HbF.

Embryonic Haemoglobin:
Haemoglobin Gower 1 (HbE Gower-1)
Haemoglobin Gower 2 (HbE Gower-2)
Haemoglobin Portland I (HbE Portland-1)
Haemoglobin Portland II (HbE Portland-2)

Fetal Haemoglobin (haemoglobin F, HbF)

The patient is presenting with classic symptoms of round ligament pain.
Round ligaments are structures which extends from the lateral portion of the uterus below to the oviduct and will travel downward in a fold of peritoneum to the inguinal canal to get inserted in the upper portion of the labium majus. As the gravid uterus grows out of pelvis during pregnancy, these ligaments will stretch, mostly during sudden movements, resulting in a sharp pain. Due to dextrorotation of uterus, which occurs commonly in pregnancy, the round ligament pain is experienced more frequently over the right side. Usually this pain improves by avoiding sudden movements, by rising and sitting down gradually, by the application of local heat and by using analgesics.

As the patient is not experiencing any symptoms like fever or anorexia a diagnosis of appendicitis is not likely. Also in pregnant women appendicitis often presents as pain located much higher than the groin area as the growing gravid uterus pushes the appendix out of pelvis.

As the pain is localized to only one side of groin and is alleviated with a heating pad the diagnosis of preterm labor is unlikely. In addition, the pain would persist even at rest and not with just movement in case of labor.

As the patient has not reported of any urinary symptoms diagnosis of urinary tract infection is unlikely.

Kidney stones usually presents with pain in the back and not lower in the groin. In addition, with a kidney stone the pain would occur not only with movement, but would persist at rest as well. So a diagnosis of kidney stone is unlikely in this case.

In the period immediately after the delivery of the placenta, known as the puerperium, the female reproductive system begins to undergo some physiological changes to return to a non-pregnant state. One of these changes is uterine involution. The myometrium contracts, constricting blood vessels which impedes blood flow. It is thought that the uterine tissues then undergo apoptosis and autophagy. It takes about 4-6 weeks for the uterus to decrease is size from about 1 kg to 60 grams.

The Sella turcica is composed of three parts:
1. The tuberculum sellae (horn of saddle): a variable slight to prominent median elevation forming the posterior
boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.
2. The hypophysial fossa (pituitary fossa): a median depression (seat of saddle) in the body of the sphenoid that accommodates the pituitary gland (L. hypophysis).
3. The dorsum sellae (back of saddle): a square plate of bone projecting superiorly from the body of the sphenoid.
It forms the posterior boundary of the Sella turcica, and its prominent superolateral angles make up the posterior clinoid processes.

A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK. An inevitable miscarriage occurs with the usual symptoms of a miscarriage such as menstrual-like cramping, vaginal bleeding and a dilated cervix. The gestational sac has ruptured but products of conception have not been passed. The products of conception will eventually pass.

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

The internal anal sphincter is innervated by pelvic splanchnic nerves

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

WHO defines perinatal death as the number of still births and death in the first week of life per 1000 births.

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).

The chorionic plate represents the fetal surface of the placenta, which in turn is covered by the amnion. The amnion is composed of a single layered epithelium and the amnionic mesenchyme, an avascular connective tissue. The amnionic mesenchyme is only weakly attached to the chorionic mesenchyme and can easily be removed from the delivered placenta. The chorionic mesenchyme contains the chorionic vessels that are continuous with the vessels of the umbilical cord. Within the mesoderm of secondary villi, haematopoietic progenitor cells develop and start to differentiate. At about day 20 post-conception, first placental blood cells and endothelial cells develop independent of the vascular system of the embryo proper.13 14 The development of first placental vessels transforms the respective villi into tertiary villi.

An LSIL Pap test shows mild cellular changes. The risk of a high-grade cervical precancer or cancer after an LSIL Pap test is as high as 19 percent.

As with an ASC-US Pap test, an LSIL Pap test is evaluated differently depending upon age.

For women ages 25 or older, follow-up depends upon the results of human papillomavirus (HPV) testing:

– Women who test positive for HPV or who have not been tested for HPV should have colposcopy.
– Women who test negative for HPV can be followed up with a Pap test and HPV test in one year.

Referring the patient to an oncologist is not acceptable since there is no established diagnosis of malignancy that has been made. All other options are unacceptable since Pap smear must be done in 12 months.

In post menopausal women the thickness of the endometrium should be 4mm or less or women on tamoxifen is should be less than 5mm. If it is more than this the patient should be worked up for endometrial carcinoma.

Premature menopause is most commonly idiopathic.

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface, resulting in a local inflammatory response and, in later pregnancy, thrombosis of the uteroplacental vasculature. This patient should be offered referral to a specialist clinic as she has had recurrent miscarriages. Low dose aspirin is one of the treatment options to prevent further miscarriage for patients with antiphospholipid syndrome.

Normal closure of the ductus arteriosus (DA) is brought about by a number of mechanisms. Upon delivery the new born babies first breath inflates the lungs and this causes a rise in pO2. Oxygen is known to cause constriction of the DA in vivo and in vitro. In addition the decreased vascular resistance means the pressure within the lumen of the DA drops aiding closure. In addition on inflation of the lungs, the lungs produce bradykinin which stimulates smooth muscle constriction of the ductus. The most important factor is thought to be the drop in Prostaglandin E2. Prostaglandin E2 maintains patency of the Ductus in the unborn child but after birth is metabolised in the lungs and its levels fall rapidly within 3 hours of birth.

The pudendal nerve provides sensory innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. Pudendal nerve blocks are indicated for analgesia of the second stage of labour, repair of an episiotomy or perineal laceration, and for minor surgeries of the lower vagina and perineum.

Tranexamic acid is an antifibrinolytic drug which is one of the treatment options in menorrhagia i.e. heavy menstrual bleeding. It acts by binding to the receptor sites on plasminogen thus preventing plasmin from attaching to those receptors thus inhibiting plasminogen activation.

If pharmaceutical treatment is appropriate NICE advise treatments should be considered in the following order:

1. levonorgestrel-releasing intrauterine system (LNG-IUS) provided at least 12 months use is anticipated
2. tranexamic acid or NSAIDs* or combined oral contraceptives (COCs) or cyclical oral progestogens
3. Consider progesterone only contraception e.g. injected long-acting progestogens

*When heavy menstrual bleeding (HMB) coexists with dysmenorrhoea NSAIDs should be preferred to tranexamic acid. Also note NSAIDs and tranexamic are appropriate to use if treatment needed pending investigations.

This patient with a previous history of pre-eclampsia and obesity is at high risk for developing pre-eclampsia.

A daily intake of 1000mg of calcium is observed to be helpful in reducing the incidence of any hypertensive disorders and preterm labour.

Vitamin A should always be avoided during pregnancy as it is fetotoxic.

All other options are incorrect.

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.

A type II deceleration is due to placental insufficiency which can result in fetal distress and asphyxia. The fetal heart rate is lowest at the start of the contraction and returns to normal after the contraction is complete.

Androgen insensitivity syndrome patients have 46XY chromosomes. They are males by genotype but appear as female because of insensitivity to male hormones. It is advisable to perform gonadectomy in these patients after puberty because these patients are at increased risk of developing malignancy.

Shoulder dystocia is a complication associated with fetal macrosomia and may result in neurological dysfunction. Fetal macrosomia is generally defined as birth weight – 4,000 g. It occurs in about 10% of pregnancies and one of the most important predictors of fetal macrosomia is previous macrosomic infant(s). The recurrence rate of fetal macrosomia is above 30%. Other risk factors are maternal diabetes, multiparity, prolonged gestation, maternal obesity, excessive weight gain, male foetus, and parental stature- Not all cases of fetal macrosomia lead to shoulder dystocia and the occurrence of this complication is only 0.5%-1% of all pregnancies.

To make clinical decision regarding management of the patient, it is important to understand that there are other factors that lead to shoulder dystocia, such as the mother’s anatomy. While statistics suggest that there’s a tendency to choose elective Caesarean delivery for suspected macrosomia, it is believed that most of procedures are unnecessary, as evidence has shown the number of complications are not reduce- Also while it is logical to consider induction of labour at the 37th week of pregnancy, it is associated with increased Caesarean deliveries because of failed inductions. The recommended course of action is watchful waiting till the patient goes in labour.

→ Induce labour at the 37th week of gestation is not the best course of action, as it is associated with high failure rate, which often leads to Caesarean delivery.
→ Schedule elective Caesarean delivery is considered unnecessary in patients who do not have diabetes. Statistics have shown no evidence that Caesarean delivery reduces the rate of complications.
→ Serial ultrasound for fetal weight estimation is incorrect. The strategies used to predict fetal macrosomia are risk factors, Leopold’s manoeuvres, and ultrasonography. Even when they are combined, they are considered inaccurate; much less ultrasonography alone.
→ At this point, blood glucose control in pregnancies associated with diabetes seems to have desired results in preventing macrosomia- A weight loss program is usually not recommended- Instead, expectant management should be considered.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.

Paracetamol is safe to take during pregnancy and has shown no harm to unborn children during studies. It is the treatment of choice for mild to moderate pain during pregnancy.

According to the Royal College of Obstetrics and Gynaecology guidelines for abortion care it advises dual antibiotic regimes for antibiotic prophylaxis.
Metronidazole 1g per rectum or 800 mg orally can be given before or at the time of the abortion in women who have tested negative for Chlamydia trachomatis infection.

Alternatively, Doxycycline (100mg oral, twice daily for 7 days) or Azithromycin 1g stat doses should be given in addition to metronidazole to be effective against Chlamydia trachomatis anaerobes.

Fetal lie describes the relationship of the long axis of the foetus with respect to the long axis of the mother.
Coronal suture is the transverse suture separating the parietal bone from the frontal bone.
Umbilical cord is composed of two arteries and one vein. the vein carries the oxygenated blood, whereas the arteries contain the deoxygenated blood.
At the time of birth, the anterior fontanelle is open and appears as a soft jelly like structure.

Her T-score puts her in the osteopenic range. The presence of fragility fractures is more important in the osteoporotic patient. Olecranon fracture is not a typical fragility fracture.

Tenderness is usually suggestive of a benign breast mass such as a breast abscess. Ultrasound is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage.

Pelvic inflammatory disease (PID) is a known risk factor in causing tubal infertility due to its role in tubal damage. The tubal infertility rate after one episode of PID is thought to be about 12.5%. After two episodes the risk increases to 25%, and 50% after three episodes. The usual causative agents are chlamydia and gonorrhoea.