First stage of the labour starts with the contractions of the uterus. With time, the no. of contractions, its duration and intensity increases. It ends once the cervix is fully dilated.

Patient mentioned in the case has developed thyrotoxicosis during pregnancy. TSH level should be tested, and if the result shows any suppressed or elevated TSH level, then it is mandatory to check for free T4 level.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

Acute fatty liver of pregnancy occurs in 1-10000 pregnancies and presents as jaundice with abdominal pain. The maternal mortality is around 20%

Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.

Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area.

The WHO defines maternal death as female death from any cause related to pregnancy or its management, including childbirth or within 42 days of termination of pregnancy. This is irrespective of the duration or site of the pregnancy.

The pudendal nerve is formed by sacral nerve roots S2, S3 and S4 almost immediately as they exit the spinal foramina. The pudendal nerve exits the pelvis via the greater sciatic foramen, travels behind the sacrospinous ligament before re-entering the pelvis via the lesser sciatic foramen. It is an important nerve to be aware of as it supplies sensation to the genitalia and can also be damaged/compressed at a number of places along its course. Image sourced from Wikipedia

An ultrasound of the foetal spine at 16-18 weeks of gestation is the most appropriate assessment (correct answer).

Ultrasound performed at 11-12 weeks of gestation can diagnose anencephaly, another neural tube defect, however; any vertebral column defect is unlikely to be detected.

In most cases of neural tube defects in the foetus, elevations will be noted in maternal alpha-fetoprotein levels at 12 to 15 weeks. However, it may not be possible to detect all such abnormalities and a confirmed diagnosis cannot be made.

Additionally, elevations in alpha-fetoprotein levels do not always correlate to the presence of foetal neural tube defects.

Nuchal translucency scans do not detect neural tube defects. They are performed to identify the risk of chromosomal abnormalities in the foetus.

Tissues with actively dividing cells, such as bone marrow and gastrointestinal mucosa, are particularly sensitive to ionising radiation. Lymphocyte depletion is the most sensitive marker of bone marrow injury, and after exposure to
a fatal dose, marrow aplasia is a common cause of death. The gonads are highly radiosensitive and radiation may result in temporary or permanent sterility. Stochastic (chance) effects occur with increasing probability
as the dose of radiation increases. Carcinogenesis represents a stochastic effect. With acute exposures, leukaemias may arise after an interval of around 2–5 years and solid tumours after an interval of about 10–20 years. Moist skin desquamation can be an acute reaction to both radio and chemotherapy whereas fibrosis and lymphoedema are late complications.

Vulvovaginal candidiasis is the most common genital infections and it is caused by candida albicans in 80-92% of the cases. It colonise the vaginal flora in 20% of non pregnant and 40% pregnant women.

Elements of the Apgar score include colour, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression or apnoea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score 7 or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.

An elevation in serum PRL is associated with a variety of reproductive disorders, including amenorrhea, oligomenorrhea, anovulation and/or luteal phase defects with subsequent infertility.

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

If a mother has been abusing drugs during antenatal period, there are some contraindications to discharge her baby home. These conditions includes:
– excessive weight loss, which is greater than ten percent of birth weigh
– suspected baby neglect or abuse
– suspected domestic violence
– a court order preventing baby from being discharged home or if there is requirement for further assessment of withdrawal symptoms.

A 2-3 percentages weight loss during the early neonatal period is considered to be a normal finding and is therefore not considered as a contraindication to discharge the baby home.

As they respond differently to different drugs, a thorough distinguishing must be done between the two major groups of epilepsies while approaching a woman, who wishes to become pregnant while on antiepileptic drugs.

Partial epilepsies will respond to most of the antiepileptic drugs, but in case of idiopathic generalized epilepsies, especially in juvenile myoclonic epilepsy, seizure can be controlled only with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful but substitution of sodium valproate with lamotrigine is not the right choice. This is because lamotrigine is not as effective as sodium valproate and will sometimes worsens myoclonic seizures in juvenile myoclonic epilepsy.

Topiramate and levetiracetam are found to be effective in idiopathic generalized epilepsy, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially in myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there will be no effective alternative to sodium valproate as cessation of sodium valproate will lead to recurrence of the generalized seizures, especially juvenile myoclonic epilepsy. Hence, it is not advisable to discontinue the drug in auch patients.

On the other hand, sodium valproate have the highest reported teratogenicity potential among antiepileptic drugs and the Australian Pregnancy Register has reported the risk to be as high as 16% if used in first trimester. Sodium valproate should be avoided in women of reproductive age and if a patient on the medication is willing to become pregnant, she should be well informed about the risk of teratogenicity and the decision must be left to her. If she decides to accept the risks and continue with pregnancy, the lowest possible effective dose should be prescribed to her.

If the dose of sodium valproate has been reduced to minimum during pregnancy to reduce the possible teratogenesis, it is recommended to re-establish the prepartum effective dose before the onset of labor. This is because, it is the time with increased risk for seizures, especially in patients with idiopathic generalised epilepsy who are very sensitive to sleep deprivation. Valproate therapy is found to be safe during breastfeeding.

The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. Pregnancy is a state of increased requirement of macro and micronutrients, and malnourishment or inadequate dietary intake before and during pregnancy, can lead to adverse perinatal outcomes. Many nutritional interventions have been proposed for pregnant mothers. These include multiple micronutrients (MMN), iron/folate, balanced protein energy, calcium, zinc and folic acid supplementation.

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 metabolic adaptations of pregnancy are orchestrated by hormones produced by the placenta and maternal pituitary gland, which undergo dramatic changes during gestation. After involution of ovarian sex steroid production by wk 6, placental oestrogen and progesterone production increases exponentially to term. Concurrently, there are progressive increases in prolactin (PRL), produced by the maternal pituitary gland and decidua, and human chorionic somatomammotropin (CSH, also called human placental lactogen), which has structural similarities to GH and PRL.

A serious complication with a miscarriage is DIC, a severe blood clotting condition and is more likely if there is a long time until the foetus and other tissues are passed, which is often the case in missed abortion.

Disseminated intravascular coagulation (DIC) in pregnancy is the most common cause of an abnormal haemorrhage tendency during pregnancy and the puerperium. Although pregnancy itself can cause DIC, its presence is invariably evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead foetus, amniotic fluid embolism, placental retention or bacterial sepsis.

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 is not an X-linked condition so the sex of the child makes no difference to the inheritance. Any child will have a 1 in 4 chance of having beta thalassaemia major.

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.

Placental abruption is defined as the premature separation of placenta from uterus and the condition usually presents with bleeding, uterine contractions and fetal distress. It is one of the most significant cause of third-trimester bleeding and is often associated with fetal and maternal mortality and morbidity. In all pregnant women with vaginal bleeding in the second half of the pregnancy, this condition should be considered as a differential diagnoses.
Though vaginal bleeding is the most common presenting symptom reported by almost 80% of women with placental abruption, vaginal bleeding is concealed in 20% of women with placental abruption, therefore, absence of vaginal bleeding does not exclude placental abruption.

Symptoms and complications of placental abruption varies according to patient, frequency of appearance of some common features is as follows:
‌- Vaginal bleeding is the common presentation in 80% of patients.
‌- Abdominal or lower back pain with uterine tenderness is found in 70%
‌- Fetal distress is seen in 60% of women.
‌- Abnormal uterine contractions like hypertonic, high frequency contractions are seen in 35% cases.
‌- Idiopathic premature labor in 25% of patients.
‌- Fetal death in about 15% of cases.

Examination findings include vaginal bleeding, uterine contractions with or without tenderness, shock, absence of fetal heart sounds and increased fundal height due to an expanding hematoma. Shock is seen in class 3 placental abruption which represents almost 24% of all cases of placental abruption.

Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include post thrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation.

Low molecular weight heparin (LMWH) is the preferred agent for prophylaxis and treatment of DVT during pregnancy. A disadvantage of LMWH over unfractionated heparin (UFH) is its longer half-life, which may be a problem at the time of delivery.

Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.

Oxytocin is the primary stimulus for uterine involution following childbirth.

Mullerian agenesis occurs in 1 in 5000 to 1 in 40000 girls. The Mullerian system does not develop which results in an absent uterus and upper vagina. This condition is also known as Rokitansky-Kuster-Hauser syndrome, The ovarian function is normal and so the most common presentation is amenorrhea in the presence of an otherwise normal pubertal development.

CA-125 has found application as a tumour marker or biomarker that may be elevated in the blood of some patients with specific types of cancers, or other conditions that are benign. Increased level of CA125 appears in fifty percent of stage 1 ovarian cancer patients and more than 90% with stages 2-4 ovarian cancer. CA-125 is therefore a useful tool for detecting ovarian cancer after the onset of symptoms as well as monitoring response to treatment and for predicting a patient’s prognosis after treatment.

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.

These are features of excess growth hormone i.e. Acromegaly. Down’s and Cri du chat typically cause Micrognathia (small jaw)

Second-trimester ultrasound markers have low sensitivity and specificity for detecting Down syndrome, especially in a low-risk population.

The highest detection rate is acquired with ultrasound markers combined with gross anomalies. Although the detection rate with this combination of markers is high in a high-risk population (50 to 75 percent), false-positive rates are also high (22 percent for a 100 percent Down syndrome detection rate).

Placental abnormalities such as placenta previa and placenta accreta are the most common reasons for considering hysterectomy as an inevitable treatment option in postpartum hemorrhage.

Placental villi normally invade only the superficial layers of endometrial deciduas basalis, but when the invasion is too deep into the uterine wall, the condition is termed as placenta accreta, increta or percreta depending on the depth of invasion.
– When the villi invade the deeper layers of the endometrial deciduus basalis, but not the myometrium it is called as Placenta accreta. This is the most common type of decidual invasion and accounts for approximately 75% of the cases.
– When the villi invade the myometrium, but do not reach the uterine serosa or the bladder is called Placenta increta. This type accounts for nearly 15% of cases.
– In cases were the villi invades into the uterine serosa or the bladder is it called as Placenta percreta and this happens in 5% of cases.

Prior uterine surgery is the main risk factor for placenta accreta and the best management is elective cesarean hysterectomy.
postpartum hemorrhage can also be caused by conditions like genital lacerations, uterine atony, retained products of conception and uterine inversion. In most of these above mentioned cases, hysterectomy is not required and remains as the last resort in extremely desperate situations.

NOTE– Though uterine atony is the most common cause of postpartum hemorrhage, it is often manageable medically.

The Joel Cohen incision is superior to the Pffannenstiel incision. It is a straight incision that is 3 cm below the line joining the anterior iliac spines.

Ovulation usually occurs on day 14 in a typical 28-day cycle. Luteinizing hormone levels spike as a result of increased oestrogen levels secreted from maturing follicles. This LH spike occurs about 24-36 hours before the release of the oocyte from the mature follicle.

Dermoid cysts and teratomas contain elements from multiple germ cell layers. They are often considered the same entity (even in medical texts) however a dermoid is composed only of dermal and epidermal elements. A teratoma has mesodermal and endodermal elements Mature teratomas are composed of well-differentiated derivations from at least 2/3 germ cell layers (i.e. ectoderm, mesoderm, and endoderm). They contain developmentally mature skin complete with hair follicles, sweat glands, sometimes hair, and sometimes sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue.

Evidence is not yet of sufficient quality for there to be evidence-based guidelines or recommendations. Having excluded other causes:

Reassure patients that breakthrough bleeding is a common side-effect of CHC and usually resolves after three cycles of use.
Advise women who smoke that stopping smoking may improve cycle control.
If bleeding persists after three cycles, consider changing formulation:
Increase dose of oestrogen, particularly if on a 20-microgram ethinylestradiol (EE) preparation

All other options are not acceptable.

Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.

In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.

SPIKES protocol for delivering serious news to patients includes:
– Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
– Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
– Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
– Knowledge:
Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
– Empathy: Express understanding & give support when responding to emotions
– Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.

The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases.  In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal.  When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with.  For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later.  The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.

These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.

This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.

This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.

While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.

Dysplasia has 4 microscopic characteristics:
Anisocytosis (unequal cell size)
Poikilocytosis (abnormal cell shape)
Hyperchromatism (pigmentation)
Mitotic figures (increased cells currently dividing)

Hyperplasia and hypertrophy is characterised by increase in cell number and increase in cell size respectively, whereas atrophy means decrease in cell size.
Metaplasia is characterised by change of one form of cell to another type e.g. changes of columnar epithelium to squamous epithelium.

HPV infects the squamous cells that line the inner surfaces of these organs. For this reason, most HPV-related cancers are a type of cancer called squamous cell carcinoma. Some cervical cancers come from HPV infection of gland cells in the cervix and are called adenocarcinomas.

HPV-related cancers include:

Cervical cancer: Virtually all cervical cancers are caused by HPV. Routine screening can prevent most cervical cancers by allowing health care providers to find and remove precancerous cells before they develop into cancer. As a result, cervical cancer incidence rates in the United States are decreasing.

Oropharyngeal cancers: Most of these cancers, which develop in the throat (usually the tonsils or the back of the tongue), are caused by HPV (70% of those in the United States). The number of new cases is increasing each year, and oropharyngeal cancers are now the most common HPV-related cancer in the United States.

Anal cancer: Over 90% of anal cancers are caused by HPV. The number of new cases and deaths from anal cancer are increasing each year. Anal cancer is nearly twice as common in women as in men. Learn more about anal cancer statistics.

Penile cancer: Most penile cancers (over 60%) are caused by HPV.
Vaginal cancer: Most vaginal cancers (75%) are caused by HPV. Learn about symptoms of, and treatment for, vaginal cancer, a rare type of cancer.

Vulvar cancer: Most vulvar cancers (70%) are caused by HPV.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

The use of lamotrigine during pregnancy has not been associated with an increased risk of neural tube defects; however, the recommendation regarding higher doses of folic acid supplementation is often, but not always, broadened to include women taking any anticonvulsant, including lamotrigine.

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.

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.

Increasing sample size decreases type 2 errors and increases power of the results. Sensitivity and specificity of the test should remain constant regardless of sample size. Confidence intervals are applied by a statistician and are dependent on the mean.

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.

Arcuate means ‘bow shaped’ and there are different arcuate lines in anatomical terms. Regarding the pelvic brim this is composed of the arcuate line of the ilium, pectineal line and prominences of sacrum and pubic symphysis (as demonstrated in the images below). As can be seen the arcuate line is a smooth rounded border on the internal surface of the ilium inferior to the iliac fossa and Iliacus. Image sourced from Wikipedia Note: The pelvic outlet is also called the inferior aperture. The pelvic brim is the superior aperture

The testicular artery arises from the aorta and supplies the testis and the epididymis. The testis is supplied by 3 arteries.: Testicular artery, cremasteric artery that arises from the inferior hypogastric artery and the artery to the vas deferens from the internal iliac artery.

Risk factors of fibroids include early menarche, nulliparity, early exposure to oral contraceptives (one study showed 13-16 years old), diet rich in red meats and alcohol, vitamin D deficiency, hypertension, obesity, and/or history of sexual or physical abuse.

Smoking is associated with actual reduced risk due to an unknown mechanism.

20% of the patients with breast cancer will have hypercalcemia.

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.

If the patient has a negative Chlamydia screen then a stat dose of metronidazole monotherapy is appropriate. You do not know this patients Chlamydia status and therefore dual therapy with metronidazole + doxycycline or azithromycin is appropriate.

This is stage 2B.

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

A pH value below than 7.18 indicates acidosis which can result in hypoxic brain injury. In order to prevent brain injury, immediate delivery of the foetus should be planned. The normal range for a term baby is pH: 7.18 – 7.38, preterm pH: 7.14 – 7.4.

Fetal urine contributes significantly to amniotic fluid production in the second trimester of pregnancy. As early as 8-11 weeks, urine production begins and can be observed in the fetal bladder on ultrasound scans. The urine creates a hypotonic fluid which contains increasing concentrations of urea and creatinine. By term, a foetus produces about 800 ml of urine a day, of which 250ml is eliminated through fetal swallowing.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour is having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.

Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.

Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.

The following treatment regimes are recommended for the treatment of Chlamydia in Pregnancy: Erythromycin 500mg four times a day for 7 days or Erythromycin 500 mg twice a day for 14 days or Amoxicillin 500 mg three times a day for 7 days or Azithromycin 1 gm stat (only if no alternative, safety in pregnancy not fully assessed) The following treatment regimes are recommended for the treatment of Chlamydia in NON-PREGNANT patients: Doxycycline 100mg bd for 7 days OR Azithromycin 1gm orally in a single dose NOTE: Doxycycline and Ofloxacin are contraindicated in pregnancy

As B-HCG and TSH have similar structures, increased B-HCG can lead to hyperthyroidism, however there is only a 3% chance of this happening.

WHO guidelines
Semen volume: Greater than or equal to 1.5 ml
pH: Greater than or equal to 7.2
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
Total sperm number: 39 million spermatozoa per ejaculate or more
Total motility (% of progressive motility and nonprogressive motility): 40% or more motile or 32% or more with progressive motility
Vitality: 58% or more live spermatozoa
Sperm morphology (percentage of normal forms): 4% or more

Prolactin is the hormone that is responsible for the production of milk (Lactogenesis). Oxytocin is responsible for the let down reflex during suckling.

Prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in preparation for the production of milk. However, milk is not secreted then, because progesterone and oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.

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

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

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

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

BP over 159/109 is classed as Severe. NICE guidance advises admission and treatment with oral Labetalol as 1st Line. Patient should have BP checked QDS and shouldn’t be discharged until BP is below 159/109

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

1. First-degree trauma corresponds to lacerations of the skin/vaginal epithelium alone.
2. Second-degree tears involve perineal muscles and therefore include episiotomies.
3. Third-degree extensions involve any part of the anal sphincter complex (external and internal sphincters):
i Less than 50 per cent of the external anal
sphincter is torn.
ii More than 50 per cent of the external anal
sphincter is torn.
iii Tear involves the internal anal sphincter
(usually there is complete disruption of the
external sphincter).
4. Fourth-degree tears involve injury to the anal sphincter complex extending into the rectal mucosa.

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

According to the laboratory reports, patient has developed urinary tract infection and should be treated with one week course of oral antibiotics.
As the patient is pregnant, antibiotics like cephalexin, co-amoxiclav and nitrofurantoin must be considered as these are safe during pregnancy.

Due to this Patient’s allergic history to penicillin, cephalexin can be considered as the best option. Risk of cross allergy would have been higher if the patient had any history of anaphylactic reactions to penicillin.

In Australia, Amoxicillin is not recommended to treat UTI due to resistance.Tetracyclines also should be avoided during pregnancy due to its teratogenic property.

Glomerular filtration rate (GFR) rises immediately after conception and increases by about 50 per cent overall, reaching its maximum at the end of the first trimester. GFR then falls by about 20 per cent in the third trimester, returning to pre-pregnancy levels within 12 weeks of delivery.

There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.

The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.

Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

Paroxetine is an SSRI used for hot flushes in women with contraindication for hormonal therapy.

Hormonal or other pharmacotherapy is usually needed for women with bothersome hot flashes. For most women with moderate to very severe hot flashes and no contraindications, we suggest MHT. Women with an intact uterus need both oestrogen and a progestin, while those who have undergone hysterectomy can receive oestrogen only. For women interested in MHT, the first step is to determine the potential risks for the specific individual.

The majority of perimenopausal and recently menopausal women are good candidates for short-term hormone therapy for symptom relief. However, for women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event (VTE) or stroke, or those at moderate or high risk for these complications, alternatives to hormone therapy should be suggested. For women with moderate to severe hot flashes who are not candidates for hormone therapy based upon their breast cancer, CHD, or VTE risk and for those who choose not to take MHT, we suggest nonhormonal agents. The agents most commonly used include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs.

Black Cohosh is found to be no more significant than placebo.
Long-term use of mefenamic acid is controversial and not recommended.

Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.

The internal anal sphincter is innervated by pelvic splanchnic nerves

The urinary bladder, and most of the urinary structures are lined by epithelium called the urothelium, or the transitional epithelium. This stratified lining is divided into three parts, an apical layer, an intermediate layer and a basal layer. The transitional epithelium is available to stretch to accommodate the increased volume when the bladder is distended, without structural damage.

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.

The lower vagina drains to the inguinal nodes where as the upper vagina drains to the internal and external iliacs

The Corpus Luteum is a temporary endocrine structure that secretes two steroid hormones: 1. Progesterone (17a Hydroxyprogesterone) and 2. Oestradiol. The corpus luteum also secretes Inhibin A. In the menstrual cycle if fertilisation doesn’t occur the corpus luteum stops secreting progesterone and degenerates into a corpus albicans. If fertilisation occurs hCG signals the corpus to continue progesterone production and it is then termed the corpus luteum graviditatis

The pubic symphysis or symphysis pubis is the midline cartilaginous joint (secondary cartilaginous) uniting the superior rami of the left and right pubic bones. It is located anterior to the urinary bladder and superior to it.

The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.

Staph aureus is the most common causative organism of skin and soft tissue infections.

This patient is above 35 and smokes more than 15 cigarettes per day, which is an absolute contraindication to using a combined oral contraceptive pill. A BMI of greater than 35 is a relative contraindication to the usage of the combined oral contraceptive pill.
Progestogen-only contraception, such as etonogestrel implant, levonorgestrel intrauterine device, and depot medroxyprogesterone, should be offered to her.
Without initially attempting lifestyle changes, a referral for weight loss surgery is not required. Also, nicotine replacement therapy may aid in quitting smoking, but it may take time.

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

Oestrogen is secreted by the corpus luteum and is responsible for the proliferation of the endometrium to prepare it for the implantation of the zygote.

CVS has decreased in frequency with the recent increased uptake of cell-free DNA screening. It remains the only diagnostic test available in the first trimester and allows for diagnostic analyses, including fluorescence in situ hybridization (FISH), karyotype, microarray, molecular testing, and gene sequencing. CVS is performed between 10 and 14 weeks’ gestation. CVS has been performed before 9 weeks in the past, though this has shown to increase the risk of limb deformities and, therefore, is no longer recommended.

There are between 250 and 400 lobules in each testis. The lobule is a structural unit of the testis with each lobule contained in one of the intervals between fibrous septa which extend between the mediastinum testis and the tunica albuginea. Each lobule contains 1 to 3 seminiferous tubules.

For a diagnosis of Preeclampsia to be established, hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week should be present.

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.

Most of the cases of down syndrome occur due to non disjunction trisomy 21 which is associated with increased maternal age. The non disjunction occurs in the maternal gametes.

Shoulder dystocia occurs when the fetal shoulder impacts on the maternal symphysis or sacrum during vaginal delivery. About 10% of babies with shoulder dystocia will suffer a brachial plexus injury, the most common one being Erb-Duchenne palsy. In Erb’s palsy, the upper nerve roots C5 and C6 are damaged due to excessive widening of the angle between the head and the shoulder. This causing temporary paralysis in the affected arm whereby the infant will present with its hand hanging limp by his side, internal rotation of the forearm, plus wrist and finger flexion. This sign is called the ‘waiter’s tip hand’. The palsy usually resolves spontaneously in a large proportion of cases.

This patient should be given promethazine and codeine as she presents with severe migraine.

Usage of metoclopramide is safe during pregnancy and for increasing effectiveness it can be added to paracetamol. However, because of its risk for causing extrapyramidal effects it should be used only as a second-line therapy and Promethazine should be considered as the first line choice of remedy. So the answer is Codeine and promethazine.

Opioid pain relievers such as codeine are not been reported of having any associated with increased birth defects or miscarriage, but its long-term use can lead to dependency in mother and withdrawal signs in the baby.

Paracetamol alone or combined with codeine is not found to be useful in controlling vomiting.

It is advised to completely avoid dihydroergotamine and the triptans throughout pregnancy.

The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

The ureters receive innervation by a number of nerve plexuses. The nerves supplying the ureters originate from spinal segments T11 to L2. When you think about ureteric colic giving classic ‘loin to groin’ pain it is because the pain is referred to these dermatomes.

Chlamydia trachomatis (D-K subtypes) is the most common cause in this age group and fits the descriptors given.

Fibrinogen is activated by thrombin which converts it into fibrin which forms a mesh to trap red blood cells and form a clot.

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)

The diagnosis of listeria depends on clinical suspicion and isolation of the organism from blood, vaginal swabs or the placenta. Meconium staining of the amniotic fluid in a preterm foetus may increase clinical suspicion for listeriosis. For women with listeriosis during pregnancy, intravenous antibiotic treatment (ampicillin 2 g given every 6 hours) is indicated.

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

The management of low-grade squamous intraepithelial lesions (LSIL) on cervical cytology in women ages 25 years or older depends upon whether the patient underwent high-risk human papillomavirus (HPV) testing.

Women in this age group comprise two different populations in terms of cervical cancer screening strategies. Professional organizations recommend that women ages 25 to 29 years be screened with cytology alone, while women 30 years or older should be screened with cytology and HPV co-testing. Thus, the American Society for Colposcopy and Cervical Pathology (ASCCP) prefers that women ages 25 to 29 years are not managed based upon HPV results, even if an HPV test was performed at the time of screening. For women with ages 30 years or older and HPV positive, colposcopy must be performed.