The Rubella virus, also known as German measles, is found in the Togavirus family and is a single-stranded RNA virus. The virus, which is acquired through contact with respiratory secretions, primarily replicates in the nasopharynx and lymph nodes, and produces a mild and self-limiting illness. Congenital infection, however, is associated with several anomalies including sensorineural deafness, cataracts and cardiac abnormalities.

Antepartum haemorrhage presents with bleeding, which may or may not be accompanied by pain. Uterine irritability would suggest abruptio, however contractions are present which may be confused with uterine irritability and in this case, there are no signs of pre-eclampsia present.

Erb’s or Erb-Duchenne palsy is a type of brachial plexus injury. The brachial plexus comprises C5 to T1 nerve roots. In Erb’s palsy C5 and C6 are the roots primarily affected. Shoulder Dystocia is the most common cause of Erb’s palsy.

Cystic fibrosis is the most common fetal genetic disease in Caucasians and has an autosomal recessive inheritance. It is caused by an abnormal chloride channel due to a defect in the CFTR gene. Complications range from haemoptysis, respiratory failure, biliary cirrhosis, diabetes and male infertility. Men with CF are infertile in 98% of the cases due to failure of development of the vas deference.

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.

When symptoms are present, they may include abdominal pain, mass or swelling, and abnormal uterine bleeding. Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent. When abdominal pain is present, it usually is constant and ranges from slight to moderate in intensity.

Mucinous cystadenomas are relatively common (12% to 15% of all ovarian tumours). They can become massive. These tumours usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence.

Corpus luteal cysts present with irregular menses, abdominal fullness due to fluid build up and pelvic pressure.

Endometriosis mainly presents with cyclic pain at site of involvement and dysmenorrhea.

Placenta previa typically presents with painless bright red vaginal bleeding usually in the second to third trimester. Although it’s a condition that sometimes resolves by itself, bleeding may result in serious complications for the mother and the baby and so it should be managed as soon as possible.

At about 8-12 weeks gestation, normal physiological herniation of the fetal bowel occurs. The midgut protrudes into the base of the umbilicus, and undergoes a 90-degree anticlockwise rotation. When the abdominal cavity enlarges enough to fit the developing midgut, the intestines undergo another 180-degree rotation before returning to the abdominal cavity.

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.

It is essential to notice the important details mentioned in the case scenario. These would be the details about her menstruation, a smaller than dates uterus and an open cervix. A smaller than expected uterine size could be caused by her passing out some tissue earlier or it could be due to the foetus having been dead for some time. The finding of an open cervix would be in line with the fact that she had passed out some fetal tissue or it could signify that she is experiencing an inevitable miscarriage (while all fetal tissue is still kept within her uterus).

The likely diagnoses that should be considered for this case would be miscarriage (threatened, incomplete, complete and missed), cervical insufficiency, and ectopic pregnancy. A smaller than dates uterus and an open cervix makes threatened abortion an unlikely diagnosis. Her clinical findings could be expected in both an incomplete abortion and a complete abortion.
In ectopic pregnancy, although there would be a smaller than dates uterus, the cervical os would usually be closed. Cervical insufficiency is probable due to an open os but the uterine size would be expected to correspond to her dates, making it also less likely than a miscarriage.

Since she most likely has had a miscarriage (be it incomplete or complete), the next best step would be to do a per vaginal ultrasound scan which could show whether or not products of conception are still present within the uterine cavity. If present, it would be an incomplete miscarriage which would warrant a dilatation and curettage; if absent, it is a complete miscarriage so D&C would not be needed.

In view of her open cervix and 12 weeks of amenorrhea, there is no indication for a pregnancy test nor assessment of her beta-hCG levels. Cervical ligation would only be indicated if the underlying issue was cervical incompetence, which is not in this case.

Some confusion regarding breast cancer screening arose in 2009 when the U.S. Preventive Services Task Force (USPSTF) issued new mammogram guidelines. The task force recommended that screening mammograms be conducted every two years, beginning at age 50, for women with an average risk of breast cancer. For women aged 40 to 49, the decision of whether to have annual mammograms should be based on a patient’s consideration of risks vs. benefits, according to the task force.

There is no evidence that frequent screening for women on HRT helps with early detection of malignancy.

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.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

Anencephaly means the missing of a particular portion of the scalp and brain tissue. The other factors listed are associated with umbilical cord prolapse like multiparity, twin birth, polyhydramnios, premature delivery, long umbilical cord or breech presentation.

The history is typical of Intrahepatic Cholestasis of Pregnancy, also known as obstetric cholestasis and prurigo gravidarum. The features are: Intense itching typically of the hands and feet Itch gets worse at night Responds poorly to antihistamines There is no rash. The mechanism is poorly understood but tests may show deranged LFTs. It usually resolves quickly after delivery. The other diagnoses listed are possible though less likely. Scabies normally has a rash

Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management.

Absolute contraindications to endometrial ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In general, endometrial ablation should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm).

Detrusor contraction is via Parasympathetic innervation of pelvic splanchnic nerves (S2-4). This also causes relaxation of the internal urethral sphincter Note contraction and relaxation of the external urethral sphincter is under somatic control.

Serum prolactin levels are increased during suckling. Some other conditions in which serum prolactin is increased consist of: prolactin secreting brain tumours, anti psychotic drugs and hypothyroidism. It can also be increased in pregnancy, nipple stimulation and stress.

Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. It can be a sign of serious underlying pathology and is usually alarming for patients. About one-third of patients also have abnormal uterine bleeding that is not associated with coitus and about 15 percent have dyspareunia. The most serious cause of postcoital bleeding is cervical cancer. About 11 percent of women with cervical cancer present with postcoital bleeding. The patient should undergo cervical cancer screening according to local guidelines. Postcoital bleeding is not an indication for cervical cytology if previous screening tests are up-to-date and normal.

Cervical screening and liquid based cytology are superior to transvaginal ultrasound.

Coagulation profile can be done if cytology is normal to rule out bleeding diathesis.

Tranexamic acid can be considered once malignancy is ruled out and cause of bleeding has been established.

Oestrogen- and progesterone-containing oral contraceptives inhibit LH, which suppresses the FSH and LH levels, preventing follicular development and ovulation. Combined pills suppress FSH and LH throughout the cycle, inhibit endometrial proliferation, and produce a scanty cervical mucus. 

During mid secretory phase, the endometrium cells undergo distension, become more tortuous and are lined by columnar cells.
In the early proliferative phase, the glandular epithelium is cubo-columnar, while in the late proliferative phase, the glands increase in size, becoming tortuous and there is pseudostratification of the epithelium.

Remember SYMPATHETIC is STORAGE PARASYMPATHETIC is PEEING

In pregnancy, progesterone is produced by the corpus luteum followed by the placenta- Exogenous progesterone will not lead to withdrawal bleeding. In ovarian failure as well as pituitary failure, no oestrogen stimulation of the endometrium exists, and progesterone cannot cause withdrawal bleeding. With Mullerian agenesis, there is no endometrium. Polycystic ovarian syndrome has an abundance of circulating oestrogen, so the endometrium will proliferate.

→ In pregnancy progesterone withdrawal will not occur since the corpus luteum is producing progesterone- The placenta will take over, starting at 7 weeks, and will be the sole producer of progesterone by 12 weeks.
→ In ovarian failure no oestrogen will be produced; no proliferation of the endometrium will occur.
→ Pituitary failure is an incorrect answer because without gonadotropin stimulation, there will not be enough oestrogen to stimulate the endometrial lining.
→ Mullerian agenesis is an incorrect answer – there is no uterus, thus no bleeding.

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to rapid and severe haemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labour or rapid forceful labour, especially if stimulated.

Osteogenesis imperfect is an autosomal dominant condition. All the rest of the options are autosomal recessive conditions.

Basophils are granulocytic white blood cells. They express IgE antibody on their surface and react to release prostaglandins and leukotrienes to mediate an inflammatory, allergic reaction.
Blood Cell Lifespans:
Red Blood Cells 120 days
Platelets 5-9 days
White blood cells 2-5 days

Neutrophils (up to 5 days)
Basophils (2 to 3 days)
Eosinophils (2 to 5 days)
Monocytes (1 to 5 days)
Lymphocytes (variable)

SLE is a type III hypersensitivity reaction

In the foetus, the hypogastric artery ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

Bradycardia of <100 bpm for more than 5 minutes or <80 for more than 3 minutes is always considered abnormal. The given case describes fetal bradycardia detected on fetal heart auscultation and the most common causes for severe bradycardia are prolonged cord compression, cord prolapse, epidural and spinal anesthesia, maternal seizures and rapid fetal descent. Immediate management including identification of any reversible causes for the abnormality and initiation of appropriate actions like maternal repositioning, correction of maternal  hypotension, rehydration with  intravenous fluid,  cessation of oxytocin, tocolysis for excessive uterine activity, and initiation or maintenance of continuous CTG should be considered in clinical situations where abnormal fetal heart rate patterns are noticed. Consideration of further fetal evaluation and delivery if a significant abnormality persists are very important. The next step in this scenario where the baby is in 1+ station, with an abnormal fetal heart rate detected on auscultation would be to perform a confirmatory cardiotocography (CTG) and if the CTG findings confirm the condition despite initial measures obtained, prompt action should be taken. Cord compression or prolapse should come on the top of the differential diagnoses list as the the mother shows normal general conditions, but since the cervix is 8 cm dilated, 100% effaced and the fetal head is already engaged, cord prolapse would be unlikely; therefore, repeating vaginal exam is not as important as confirmatory CTG. However a vaginal exam should be done, if the scenario indicates any possibility of cord prolapse, to exclude cord compression or prolapse. NOTE– In cases of severe prolonged bradycardia, immediate delivery is recommended, if the cause cannot be identified and corrected.

This woman who is 26 weeks pregnant, has come in contact with a child having chickenpox 48 hours ago. As her IgG antibodies were negative during prenatal testing, she has no immunity against Varicella which makes her susceptible to get chickenpox.

Prophylactic treatment is required if a susceptible pregnant woman is exposed to chickenpox, which includes administration of varicella zoster immune globulin (VZIG), within 72 hours of exposure to infection.

As the patient has already checked for and was found to be negative, checking IgG level again is not relevant. Also, it was already revealed that she is not vaccinated against varicella before pregnancy.

If the patient had any symptoms typical of chickenpox, measuring IgM would have been helpful, but patient is completely asymptomatic in this case so measuring IgM is not indicated.

Vaccine for chickenpox is contraindicated during pregnancy as it is a live vaccine.

When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.

Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.

The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.

The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.