The pelvic skeleton is formed posteriorly (in the area of the back), by the sacrum and the coccyx and laterally and anteriorly (forward and to the sides), by a pair of hip bones. Each hip bone consists of 3 sections, ilium, ischium, and pubis.

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. 

Blood in the peritoneal cavity rarely causes rigidity like that of a board (this is generally only found when chemical or purulent peritonitis is present).

When there is blood, there is usually a lot of rebound soreness and a lot of guarding.

A tubal ectopic pregnancy causes discomfort and tenderness in the lower abdomen, but it is not always localised to the side of the disease.

Shock is uncommon since the diagnosis is usually recognised before there is enough blood loss to elicit such signs.

Pelvic soreness is more prevalent than a pelvic mass that may be seen on a clinical exam.
Where a mass is visible, it could be an ectopic pregnancy, but it’s more likely to be a pregnancy surrounded by a blood clot caused by a leaking ectopic pregnancy.

Flumazenil is used for benzodiazepine overdose.
Naloxone is used for opioid overdose.
Parvolex (N-acetyl cysteine) is used for paracetamol overdose.
Protamine can be used for Heparin reversal.
Beriplex can be used for Warfarin reversal.

Clinical decision making which contraceptive regimen is optimal for an individual woman with epilepsy is one of the most challenging tasks when taking care of women with epilepsy. The bidirectional interactive potential of antiepileptic drugs (AEDs) and hormonal contraceptives needs to be taken into account. Enzyme inducing (EI)-AEDs may reduce the contraceptive efficacy of hormonal contraceptives.

If combined oral contraceptives (COCs) are used in combination with EI-AEDs, it is recommended to choose a COC containing a high progestin dose, well above the dose needed to inhibit ovulation, and to take the COC pill continuously (“long cycle therapy”). But even with the continuous intake of a COC containing a higher progestin dose contraceptive safety cannot be guaranteed, thus additional contraceptive protection may be recommended.

Progestin-only pills (POPs) are likely to be ineffective, if used in combination with EI-AEDs.

Subdermal progestogen implants are not recommended in patients on EI-AEDs, because of published high failure rates.

Depot medroxyprogesterone-acetate (MPA) injections appear to be effective, however they may not be first choice due to serious side effects (delayed return to fertility, impaired bone health).

The use of intrauterine devices is an alternative method of contraception in the majority of women, with the advantage of no relevant drug–drug interactions. The levonorgestrel intrauterine system (IUS) appears to be effective, even in women taking EI-AEDs. Likelihood of serious side effects is low in the IUS users.

Lichen Sclerosis is a destructive inflammatory condition that effects the anogenital region of women. It effects around 1 in 300 women. It destroys the subdermal layers of the skin resulting in hyalinization of the skin leading to parchment paper appearance of the skin. It is associated with vulval cancer and it is estimated that the risk of developing vulval cancer after lichen sclerosis is around 3-5%.

An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

Caesarean section is rarely needed to be done when the foetus is already dead.

Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

Androgen insensitivity syndrome means that patients are phenotypically males but they are resistant or insensitive to male androgen hormones. They do not have a uterus. Due to insensitivity to androgens these patients often have female traits but their genetic makeup is of male, 46XY.

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).

Pelvic Outlet Boundaries Anteriorly: Pubic arch Laterally: Ischial tuberosities Posterolaterally: Inferior margin of the sacrotuberous ligament Posteriorly: Tip of the coccyx Note: The pelvis outlet is also called the inferior aperture. The pelvic brim is the superior aperture

The best next line of management is to administer an oxytocic (Syntocinon) infusion.

This is because the progress of labour is slow, and it necessary to augment it. As the membranes have already ruptured, the next step is to increase the contractions and induce labour using an infusion of oxytocic (Syntocinon) infusion.

Extra fluid is also required, but this will be administered alongside the Syntocinon infusion.

A lumbar epidural block is indicated in patients with an occipito-posterior (OP) position. This should not be attempted until more pain relief is required and the progress of labour is reassessed.

A Caesarean section may be necessary due to obstructed labour or fetal distress, it is not indicated at this stage.

Taking blood and holding it in case cross-matching is ultimately required is common, but most patients do not have blood cross-matched prophylactically in case there is a need to be delivered by Caesarean section and require a transfusion.

The diagnosis of functional ovarian cyst is made when the cyst measures more than 3 cm and rarely grows more than 10 cm. It appears as a simple anechoic unilocular cyst on USS. It is usually asymptomatic. If it is symptomatic then laparoscopic cystectomy should be performed.

Most types of HRT increase the risk of breast cancer. But the risk is higher for those using combined HRT, which uses both oestrogen and progestogen. Vaginal oestrogens are not linked to an increased risk of breast cancer, whereas tibolone is. Taking HRT for 1 year or less only slightly increases breast cancer risk. However, the longer you take HRT the greater the risks are, and the longer they last.

Evidence is insufficient to conclude that long-term oestrogen therapy or hormone therapy use improves cardiovascular outcomes.

HRT containing oestrogen alone increases risk of endometrial cancer. However, this is not the case when using combined HRT.

Significant puerperal pyrexia is defined as a temperature of 38ºC or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours. A mixed flora normally colonizes the vagina with low virulence. Puerperal infection is usually polymicrobial and involves contaminants from the bowel that colonize the perineum and lower genital tract. Following delivery, natural barriers to infection are temporarily removed and therefore organisms with a pathogenic potential can ascend from the lower genital tract into the uterine cavity. Placental separation exposes a large raw area equivalent to an open wound, and retained products of conception and blood clots within the uterus can provide an excellent culture medium for infection.

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.

Combined oral contraceptive pills have an anti ovulatory function and also reduce the pain of menstruation.

In the management of postpartum haemorrhage, it is essential that the bleeding is first mechanically prevented, followed by the administration of oxytocic drugs, which cause the uterine smooth muscle to contract and clamping off bleeding sites in the endometrium. The drug of choice in the treatment protocol of PPH is 5 units of syntocin, a synthetic oxytocin uterotonic, by slow intravenous infusion. This is particularly suitable in the case of uterine atony. Other uterotonics, misoprostol, carboprost, ergometrine, can be used, but are not as effective in an emergency setting.

Ovarian granulosa cells (GC) are the major source of oestradiol synthesis. Induced by the preovulatory luteinizing hormone (LH) surge, cells of the theca and, in particular, of the granulosa cell layer profoundly change their morphological, physiological, and molecular characteristics and form the progesterone-producing corpus luteum that is responsible for maintaining pregnancy. 

In patients who have an HbA1C value above 10%, it is better to postpone pregnancy until diabetes is under control. Also in those patients with type 2 diabetes mellitus, who are suffering from severe gastroparesis, those with advanced retinopathy, with severe diabetic renal disease and severe ischemic heart disease with uncontrolled hypertension pregnancy is contraindicated.

All the other options mentioned are incorrect.

Premature menopause is most commonly idiopathic.

This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.

There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.

Preterm birth is the leading cause of neonatal morbidity and mortality not attributable to congenital anomalies or aneuploidy. It has been shown that a shortened cervix is a powerful indicator of preterm births in women with singleton and twin gestations – the shorter the cervical length, the higher the risk of spontaneous preterm birth. Ultrasound measurements of the cervix are a more accurate way of determining cervical length (CL) than using a digital method.

25 mm has been chosen as the ‘cut off’ at above which a cervix can be regarded as normal, and below which can be called short. A cervix that is less than 25 mm may be indicative of preterm birth.

CMV effects 1 in 200 pregnancies of which 30% will transmit the virus to the foetus and of which 30% foetus will be effected.

When considering immunoglobulins in neonates. There are only a few key points you are likely to be tested on. 1. IgA is resistant to stomach acid and found in large amounts in breast milk. 2. IgG is the only Ig that can cross the placenta so is key for passive neonatal immunity 3. When the neonate starts synthesising its own Ig it is IgM that is produced first.

Nuchal translucency scans and maternal screening tests simply aid in determining a risk percentage for the presence of Trisomy 21, but an accurate diagnosis cannot be reached.

Chorionic villous biopsy (CVB), amniocentesis, and cordocentesis, are all prenatal diagnostic tests that can provide a definitive diagnosis regarding the presence of foetal abnormalities.

Amniocentesis performed at 16 weeks of gestation is associated with the lowest risk for miscarriage and hence is the safest test and should be recommended to the mother (correct answer).

The miscarriage risk from a CVB is at least double the risk following amniocentesis.

Nowadays, cordocentesis is rarely used for sampling of foetal material to detect chromosomal abnormalities as the test poses an even higher risk of miscarriage compared to the other procedures discussed above.

Cervical ectropion occurs when glandular cells develop on the outside of the cervix. Many individuals with cervical ectropion do not experience symptoms.
However, the primary symptom of cervical ectropion is a red, inflamed patch at the neck of the cervix.
The transformation zone appears this way because the glandular cells are delicate and irritate easily.
Other symptoms a woman may experience include:
pain and bleeding during or after sex
pain during or after cervical screening
light discharge of mucus
spotting between periods
Symptoms may range from mild to severe when they appear.

This patient has normal pap smear and is unlikely to have cervical cancer. She has no fever and vaginal discharge which would be the presentation of Chlamydia infection.

Endometrial cancer affects mainly post menopausal women and presents with vaginal bleeding, weight loss, dysuria and dyspareunia.

The Conjoint tendon AKA Inguinal falx reinforces the posterior wall of the inguinal canal. The inguinal ligament is part of the floor.
The aponeurosis of external oblique is the major component of the anterior wall with fibres of internal oblique reinforcing the lateral part

Shoulder dystocia occurs when the anterior or posterior fetal shoulder impacts on the maternal symphysis or sacrum and may require additional manevours to release the shoulders after gentle downward traction has failed. The most common injury that can occur, is to the brachial plexus due to lateral flexion of the head during traction. This may cause a neurological disability, Erb’s Palsy ( injury to C5 and C6 of the brachial plexus) in which there is a less than 10% chance that this injury would be permanent.

The uterine artery arises from the internal iliac artery, in particular the anterior division of the internal iliac artery. Some older texts refer to the internal iliac as the hypogastric artery. The vaginal artery typically arises as its own branch of the internal iliac artery. The ovarian arteries are branches of the aorta

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.

In the given case pre-pregnancy counselling and management of chronic hypertension is very much essential.
Some commonly prescribed antihypertensive drugs like ACE inhibitors, angiotensin receptor antagonists, diuretics and most beta blockers are contraindicated or is best to be avoided before conception and during pregnancy.
Methyldopa is considered as the first line drug for the management of mild to moderate hypertension in pregnancy and is the most commonly prescribed antihypertensive for this indication.
Hydralazine can be used during any hypertensive emergencies in pregnancy.
Intake of Angiotensin receptor blockers and ACE inhibitors during the first trimester can lead to complications as they are both teratogenic; use of these drugs during second and third trimesters can result in foetal renal dysfunction, oligohydramnios and skull hypoplasia.
Diuretics can cause foetal electrolyte disturbances and significant reduction in maternal blood volume.
All beta blockers, except labetalol, can result in foetal bradycardia, and growth restriction in case its long-term use.
Calcium channel antagonists, except nifedipine, are avoided during pregnancy due to its high risk for maternal hypotension and foetal hypoxia.

Stillbirth has many causes: intrapartum complications, hypertension, diabetes, infection, congenital and genetic abnormalities, placental dysfunction, and pregnancy continuing beyond forty weeks.

In 5% of normal-appearing stillborns, a chromosomal abnormality will be detectable. With an autopsy and a chromosomal study, up to 35% of stillborns are found to have a major structural pathology, and 8% have abnormal chromosomes. After a complete evaluation, term stillbirth remains unexplained about 30% of the time. The chance of finding a cause is impacted by the age of the foetus, the experience of the caregiver, and the thoroughness of the exam. Chromosome testing for aneuploidy should be offered for all stillbirths to confirm or to seek a cause of the stillbirth. Genetic amniocentesis or chorionic villus sampling before delivery offers the highest yield.

Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

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

Adnexa refer to the anatomical area adjacent to the uterus, and contains the fallopian tube, ovary, and associated vessels, ligaments, and connective tissue. The reported incidence of adnexal masses in pregnancy ranges from 1 in 81 to 1 in 8000 pregnancies. Most of these adnexal masses are diagnosed incidentally at the time of dating or first trimester screening ultrasound (USS). Functional cyst is the most common adnexal mass in pregnancy, similar to the nonpregnant state. A corpus luteum persisting into the second trimester accounts for 13-17% of all cystic adnexal masses. Pain due to rupture, haemorrhage into the cyst, infection, venous congestion, or torsion may be of sudden onset or of a more chronic nature.

Clomiphene shouldn’t be continued for more than 6 months. The second line options are Gonadotrophins or ovarian drilling.

Human chorionic gonadotrophin (hCG) has thyrotrophic activity owing to subunit homology with thyroid-stimulating hormone (TSH) and maternal TSH production is suppressed during the first trimester of pregnancy, when hCG levels are highest. The TSH response to thyrotrophin-releasing hormone (TRH) is reduced during the first trimester but returns to normal after this. Thyroid binding globulin increases in the first 2 weeks of pregnancy and reaches a plateau by 20 weeks. This leads to increased production of total T3 (tri-iodothyronine) and T4 (thyroxine).

The ovarian arteries are considered the main blood supply for the ovaries. The ovarian arteries usually arise from the lateral aspect of the abdominal artery, though in some instances they may arise from the renal or iliac arteries.

Turner syndrome patients present with primary amenorrhea, have non functional or streak ovaries and cant conceive. They are 45X genetically.

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.

Oestrogen-containing contraceptives are not recommended for this woman since she has a history of DVT. This is most likely why she was started on POP instead of standard combination tablets prior. Progesterone is also contraindicated with a history of ectopic pregnancy and should never be used again. Barrier approaches, for example, could be applied in this woman’s case.
The following are absolute contraindications to taking just progesterone pills:
– Pregnancy
– Breast cancer
– Vaginal bleeding that hasn’t been diagnosed
– Ectopic pregnancy history or a high risk of ectopic pregnancy

Progesterone-only pills have the following relative contraindications:
– Active viral hepatitis
– Severe chronic liver disease
– Malabsorption syndrome
– Severe arterial disease
– Successfully treated breast cancer more than 5 years ago
– Concomitant use of hepatic enzyme inducing medications.

Oxytocin binds to the G protein coupled receptors that triggers the IP3 mechanism leading to an elevated intracellular calcium ion.

Asherman syndrome (intrauterine adhesions or intrauterine synechiae) occurs when scar tissue forms inside the uterus and/or the cervix. These adhesions occur after surgery of the uterus or after a dilatation and curettage.

Patients with Asherman syndrome may have light or absent menstrual periods (amenorrhea). Some have normal periods based on the surface area of the cavity that is affected. Others have no periods but have severe dysmenorrhea (pain with menstruation).

Although two-dimensional sonography may suggest adhesive disease, Asherman syndrome is more often evaluated initially with saline sonography or hysterosalpingography to demonstrate the adhesions.

This is Linea Nigra. It occurs in 3/4 of pregnancies and is due to increased melanocyte-stimulating hormone production by the placenta. This also causes melasma and darkening of the nipples.

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

The finding of ketonuria in this patient indicates profound dehydration and electrolyte loss. Immediate investigation with baseline serum electrolytes, urea, and creatinine is recommended for aid In intravenous resuscitation and rehydration.

All other assessments listed are appropriate, however, baseline electrolyte concentration is important before initiating intravenous resuscitation.

Other causes that can lead to vomiting in early pregnancy include normal pregnancy, multiple pregnancies, molar pregnancies, or urinary tract infection. Urine culture is necessary to exclude urinary tract infection, pelvic ultrasound to confirm singleton or multiple pregnancy and rule out a molar pregnancy.

An erect abdominal Xray may help to rule out an organic intestinal obstruction in this patient. Her history of an appendectomy predisposes this patient to adhesions leading to small bowel obstruction. However, it is not the immediate assessment in this case.

Before the advent of ultrasound, a quantitative hCG analysis was indicated to assess the presence of molar pregnancy. However, ultrasound is now preferred to confirm this diagnosis.

The pelvic outlet is bounded in front by the lower margin of the symphysis pubis, on each side by the descending ramus of the pubic bone, the ischial tuberosity and the sacrotuberous ligament, and posteriorly by the last piece of the sacrum. The AP diameter of the pelvic outlet is 13.5 cm and the transverse diameter is 11 cm.

The placenta is important for regulating feto-maternal blood circulation, ensuring that the two circulatory systems do not come into direct contact. The placenta receives 70-80% of the uterine blood flow into the decidual spiral arteries where nutrient, waste and gaseous exchange with fetal blood takes place via the villous core fetal vessels. Deoxygenated blood arrives at the placenta via two uterine arteries while oxygenated, nutrient-rich blood is circulated back to the foetus via a single umbilical vein. The pressure in the umbilical vein is about 20 mmHg.

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.

Mirena coil is used for contraception and for long term birth control. It causes stoppage of menstrual bleeding however, in a few cases there may be inter-menstrual spotting.

The superior mesenteric vein joins the splenic vein to form the hepatic portal vein.

The risk of transplacental transmission from mother to foetus is greater in later pregnancy i.e. 26-40 weeks. Although the risk of transmission is lower in early pregnancy, if infection does occur earlier, particularly before 10 weeks, then complications are typically more severe.

The SIJ is a synovial joint. The Pubic Symphysis is a Secondary Cartilaginous

Since the car crash happened two weeks prior, breast trauma is suggested and thus fat necrosis is the most probable diagnosis. Phyllodes tumours are typically a firm, palpable mass. These tumours are very fast-growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50, prior to menopause.

Oesophageal atresia/TE fistula may be suspected prenatally with ultrasound findings of polyhydramnios, absence of fluid in the stomach, small sized abdomen, or the presence of a dilated proximal oesophageal pouch. An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. The uncontrolled leakage of urine into the vagina is the hallmark symptom of patients with UGFs. Patients may complain of urinary incontinence or an increase in vaginal discharge following pelvic surgery or pelvic radiotherapy with or without antecedent surgery. The drainage may be continuous; however, in the presence of a very small UGF, it may be intermittent. Increased postoperative abdominal, pelvic, or flank pain; prolonged ileus; and fever should alert the physician to possible urinoma or urine ascites and mandates expeditious evaluation. Recurrent cystitis or pyelonephritis, abnormal urinary stream, and haematuria also should initiate a workup for UGF.

Urinary trace infection presents with dysuria and urgency.
Detrusor instability causes urge incontinence.
Neurogenic bladder from diabetic neuropathy would also have urgency.

Toxoplasma gondii is a protozoan parasite found in cat faeces, soil or uncooked meat. Infection occurs by ingestion of the parasite from undercooked meat or from unwashed hands. Spiramycin treatment can be used in pregnancy (a 3-week course of 2–3 g per day). This reduces the incidence of transplacental infection but has not been shown to definitively reduce the incidence of clinical congenital disease. If toxoplasmosis is found to be the cause of abnormalities detected on ultrasound scan of the foetus, then termination of pregnancy can be offered.

Hysterosalpingography is used to assess the patency of the fallopian tubes. It is performed by injection of a radio-opaque iodine based contrast. This test is contraindicated in pelvic inflammatory disease and during pregnancy. Should be performed in Follicular phase of menstrual cycle after cessation of menstrual bleeding and prior to ovulation (days 6-12).

This describes the sensory area supplied by the ilioinguinal nerve. This is a potential complication with pelvic surgery.

Mediolateral episiotomy is favoured to midline episiotomy because there is less extension of the incision and decreased chances of injury to the anal sphincter and rectum.

Fetal crown-rump length (CRL) is recommended over last menstrual period for estimating GA when measured in early pregnancy i.e. before 9 to 13+6 weeks.

During the first 8 weeks of pregnancy, concentrations of hCG in the blood and urine usually double every 24 hours. Levels of the hormone typically peak at around 10 weeks, decline until 16 weeks, then remain constant.

Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighbouring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess.

Lower abdominal pain is the cardinal presenting symptom in women with PID. The abdominal pain is usually bilateral and rarely of more than two weeks’ duration. The character of the pain is variable, and in some cases, may be quite subtle. The recent onset of pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID. The onset of pain during or shortly after menses is particularly suggestive.

Other non-specific complaints include urinary frequency and abnormal vaginal discharge.

Ovarian cyst, uterine leiomyoma, appendicitis or ectopic pregnancy do not present with fever and vaginal discharge although tenderness is noted in appendicitis and ectopic pregnancy. Therefore, these options do not explain the patient’s symptoms.

Factors shown to decrease risk of ovarian cancer are:
– Oral contraceptive use
– Higher Parity
– Breast feeding
– Hysterectomy
– Tubal Ligation
– Statins
– SLE

Progesterone gradually increases during the course of pregnancy, from 25 ng⋅mL−1 at 6 weeks’ to 150 ng⋅mL−1 at 37 weeks’ gestation. Progesterone acts as trigger of the primary respiratory centre by increasing the sensitivity of the respiratory centre to carbon dioxide, as indicated by the steeper slope of the ventilation curve in response to alveolar carbon dioxide changes. Progesterone alters the smooth muscle tone of the airways resulting in a bronchodilator effect. It also mediates hyperaemia and oedema of mucosal surfaces, causing nasal congestion.

Levator ani muscle is composed of three different muscles i.e. iliococcygeus, pubococcygeus and the puborectalis muscle. It is the main muscle that supports the organs of the pelvic cavity.
Bulbocavernosus and Ischiocavernosus muscles are located in-between the anus and scrotum and play an important role in sexual response in males.
Superficial and deep transverse perineal muscles are located in the perinium and pass in front of the anus.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor.

These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

All other options are incorrect.

Girls with Turner’s syndrome (45,X) are not at risk for malignancy. Patients with feminizing testicular syndrome with XY chromosome composition and patients with mixed gonadal dysgenesis are at risk for malignancy, and bilateral gonadectomy is performed.

Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.

The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.

The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.

As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.

Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.

Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.

The treatment of stage 1A cervical cancer is excision of the margins using the Loop electrical excision procedure (LLETZ). Hysterectomy is not necessary. This treatment enables fertility to be preserved.

2010 FIGO classification of cervical carcinoma
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis 4A Invades mucosa bladder and rectum
4B – Distant Metastasis

Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Approximately 30-40% of women with endometriosis will be sub fertile. About one third of women with endometriosis remain asymptomatic. When they do occur, symptoms, such as the following, typically reflect the area of involvement:
– Dysmenorrhea
– Heavy or irregular bleeding
– Pelvic pain
– Lower abdominal or back pain
– Dyspareunia
– Dyschezia (pain on defecation) – Often with cycles of diarrhoea and constipation
– Bloating, nausea, and vomiting
– Inguinal pain
– Pain on micturition and/or urinary frequency
– Pain during exercise

Pregnancy, appendicitis, ureteral colic and ruptured ectopic pregnancy all do not present with dysmenorrhea, pain on defecation and dyspareunia. Presence of a non tender, soft abdomen also rules out these conditions.

The contents of the femoral triangles are femoral nerve, artery and the vein. Along with the femoral sheath and lymphatics.

Transitional cell carcinoma of the bladder is most commonly caused by cigarette smoke. Other risk factors include naphthylamine, azodyes and long term cyclophosphamide use.

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.

Obstetric complications during or following a cesarean section delivery include:
-Increased risk of maternal mortality.
-Increased need for cesarean sections in the subsequent pregnancies.
-Increased risk for damage to adjacent visceral organs especially bowels and bladder.
-Increased risk of infections.

Increased risk for formation of adhesions is a complication after cesarean section and this is the correct response for the given question.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

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.

The best strategy is to commence cyclical hormone therapy using continuous daily oestrogen therapy, with medroxy progesterone acetate (MPA) given daily for 12 days each month.

This patient is most likely experiencing menopause, with symptoms caused by her oestrogen deficiency state.

Diazepam will help her to sleep and possibly alleviate her irritability, but would be unlikely to relieve the hot flushes.

Continuous therapy with oestrogen and MPA provides continuous progestogen therapy and has a high risk of causing unpredictable breakthrough vaginal bleeding, as it is only three months since the last menstrual period. This treatment is not recommended to be given within 1 – 2 years of the last period.

Oestrogen alone is not recommended for women who still have their uterus.

Progestogen alone would only be indicated in cases with contraindications to oestrogen administration.

Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.

Protein C, protein S, plasminogen and anti thrombin III are all anti thrombotic agents. Thromboplastin is a pro-thrombotic.

The most common cause of maternal mortality is Cardiovascular deaths due to post partum bleeding followed by hypertensive disorders of pregnancy, sepsis and complications of labour.

This woman has signs and symptoms suggestive of cervical insufficiency, whose clinical features include pelvic pressure, premenstrual-like cramping and backache with increased vaginal discharge. Usually these symptoms will persist for several days to weeks.
Cervical insufficiency is seen between 14 – 20 weeks of gestation, which is presented as soft effaced cervix, with minimal dilation on physical examination and a 4 cm dilated and more than 80% effaced cervix will be the clinical presentation in a more advanced case.

Placental abruption presents with painful vaginal bleeding, whereas Placenta Previa presents as painless vaginal bleeding. Both cases will lead to shock but will not show any features of cervical insufficiency.

Anaemia, polyhydramnios, large for gestational age uterus and severe hyperemesis gravidarum are the commonly associated symptoms of a twin pregnancies.

New menstrual cycle after an abortion is expected to be presented with cervical dilation however signs of effacement will not be present along with it.

Fetal production of immunoglobulin begins early on at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth, through breast milk.

Testing for beta hCG should be the first test in this case. It will rule out any pregnancy that is strongly suspected based on the patient’s history and physical examination.

Fat necrosis is often a result of a trauma or surgery. In fat necrosis the enzyme lipase releases fatty acids from triglycerides. The fatty acids combine with calcium to form soaps. These soaps appear as white chalky deposits which are firm lumps with no associated discharge. The given case has a bruise which indicates prior trauma.

Risk of fibroids is more common among African ethnicity and is also related to obesity and early puberty. The role of combined oral contraceptive pills is still debatable and its results are conflicting, whereas the risk of fibroids decreases with the increase in number of pregnancies. i.e. multiparous women have a lower risk of fibroids.

Repetitive late decelerations can be caused by fetal hypoxia which results in constriction of the vessels to circulate blood from the peripheries to more important organs of the body like the brain and heart etc.

Fetal haemoglobin (HBF) is the main haemoglobin type in the foetus and persists after birth for around 6 months. Fetal haemoglobin is composed of two alpha and two gamma subunits The alpha globulin chain is coded for by genes on Chromosome 16. Alpha Thalassemia are therefore associated with Chromosome16 defects The beta and delta globulin chains are coded for by genes on Chromosome 11. Beta and Delta Thalassemia are therefore associated with Chromosome 11 Defects

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.

Amniocentesis is a prenatal procedure performed on a pregnant woman to withdraw a small amount of amniotic fluid from the sac surrounding the foetus.
The goal of amniocentesis is to examine a small amount of this fluid to obtain information about the baby, including its sex, and to detect physical abnormalities such as Down syndrome or spina bifida.
Amniocentesis is only performed on women thought to be at higher risk of delivering a child with a birth defect.

Amniocentesis is performed between 16 and 20 weeks into the pregnancy. By around this time, the developing baby is suspended in about 130ml of amniotic fluid, which the baby constantly swallows and excretes. A thin needle is used to withdraw a small amount of this fluid from the sac surrounding the foetus.

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.

Ovarian cancer is a gynaecological cancer that commonly affects women over 40 years. Risk factors for ovarian cancer include: infertility, a family history of ovarian, breast or colorectal cancer. There are some protective factors, which include: high parity and breastfeeding, early age at menarche and late age at menopause, and combined oral contraceptives, and statins.

Among all the antiepileptic drugs sodium valproate carries the highest teratogenicity rate. The potential congenital defects caused by sodium valproate are as below:
– Neural tube defects like spina bifida, anencephaly
– Cardiac complications like congenital ventricular septal defect, aortic stenosis, patent ductus arteriosus, aberrant pulmonary artery
– Limb defects like polydactyly were more than 5 fingers are present, oligodactyly were less than 5 fingers are present, absent fingers, overlapping toes, camptodactyly which is presented as a fixed flexion deformity of one or more proximal interphalangeal joints,split hand, ulnar or tibial hypoplasia.
– Genitourinary defects like hypospadias, renal hypoplasia, hydronephrosis, duplication of calyceal system.
– Brain anomalies like hydranencephaly, porencephaly, arachnoid cysts, cerebral atrophy, partial agenesis of corpus callosum, agenesis of septum pellucidum, lissencephaly of  medial sides of occipital lobes, Dandy-Walker anomaly
– Eye anomalies like bilateral congenital cataract, optic nerve hypoplasia, tear duct anomalies, microphthalmia, bilateral iris defects, corneal opacities.
– Respiratory tract defects like tracheomalacia, lung hypoplasia,severe laryngeal hypoplasia, abnormal lobulation of the right lung, right oligemic lung which is presented with less blood flow.
– Abdominal wall defects like omphalocele
– Skin abnormalities capillary hemangioma, aplasia cutis congenital of the scalp.

Tamoxifen increases risk of endometrial hyperplasia Aromatase inhibitors such as Letrozole and Anastrozole are not associated and have not been shown to increase the risk of endometrial pathology Whereas unopposed oestrogens increase endometrial cancer risk combined oral contraceptive decrease risk

Shortly after the morula enters the uterus, around the 4th day after fertilization, a clear cystic cavity starts forming inside the morula. The fluid passes through the zona pellucida from the uterine cavity and hence forms the blastocyst.

The right ovarian vein ascends and enters the inferior vena cava and the left ovarian vein drains into the longer left renal vein.

Women with Beta-Thalassaemia require significant extra input during pregnancy. Folic acid 5 mg daily should be commenced 3 months prior to conception in these patients. NOTE Women with thalassaemia who have undergone splenectomy OR have a platelet count >600 should continue or be commenced on Aspirin (75 mg/day)

Ilioinguinal nerve injury is one of the most common nerve injuries associated with pelvic surgery.

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.