There are many different reasons for performing a delivery by Caesarean section. The four major indications accounting for greater than 70 per cent of operations are: 1. previous Caesarean section 2. dystocia 3. malpresentation 4. suspected acute fetal compromise. Other indications, such as multifetal pregnancy, abruptio placenta, placenta praevia, fetal disease and maternal disease are less common. The chances of early postpartum haemorrhage are greatly reduced in C-section deliveries.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. There are various risk factors for gestational diabetes including increasing age, ethnicity, previous still births etc.

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

Changes in the cardiovascular system in pregnancy are profound and begin early in pregnancy, such that by eight weeks’ gestation, the cardiac output has already increased by 20%. The primary event is probably peripheral vasodilatation. This is mediated by endothelium-dependent factors, including nitric oxide synthesis, upregulated by oestradiol and possibly vasodilatory prostaglandins (PGI2). Peripheral vasodilation leads to a 25–30% fall in systemic vascular resistance, and to compensate for this, cardiac output increases by around 40% during pregnancy. 

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. The primary host for the organism is the domestic cat. Humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection can lead to hydrocephalus, microcephaly, mental disability and vision loss.

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.

Placental abruption is commonly defined as the premature separation of the placenta, which complicates approximately 1% of births. During the second half of pregnancy abruption is considered an important cause for vaginal bleeding and is mostly associated with significant perinatal mortality and morbidity.
Clinical presentation of abruption varies from asymptomatic cases to those complicated with fetal death and severe maternal morbidity. Classical symptoms of placental abruption are vaginal bleeding and abdominal pain, but at times severe cases might occur with neither or just of one of these signs. In some cases the amount of vaginal bleeding may not correlates with the degree of abruption, this is because the severity of symptoms is always depend on the location of abruption, whether it is revealed or concealed and the degree of abruption.
Diagnosis of abruption is clinical and the condition should be suspected in every women who presents with vaginal bleeding, abdominal pain or both, with a history of trauma, and in those women who present with an unexplained preterm labor. All causes of abdominal pain and bleeding, like placenta previa, appendicitis, urinary tract infections, preterm labor, fibroid degeneration, ovarian pathology and muscular pain are considered as differential diagnosis of abruption.

In the given case patient has developed signs and symptoms of placental abruption, like severe vaginal bleeding with abdominal pain, whose management depends on its presentation, gestational age and the degree of maternal and fetal compromise. As the presentation is widely variable, it is important to individualize the management on a case-by-case basis. More aggressive management is desirable in cases of severe abruption, which is not appropriate in milder cases of abruption. In cases of severe abruption with fetal death, as seen in the given case, it is reasonable to allow the patient to have a vaginal delivery,regardless of gestational age, as long as the mother is stable and there are no other contraindications.
The uterus is contracting vigorously, and labor occurs rapidly and progresses, so amniotomy is mostly sufficient to speed up delivery. There is a significant risk for coagulopathy and hypovolemic shock so intravenous access should be established with aggressive replacement of blood and coagulation factors. Meticulous attention should be paid to the amount of blood loss; general investigations like complete blood count, coagulation studies and type and crossmatch should be done and the blood bank should be informed of the potential for coagulopathy. A Foley catheter should be placed and an hourly urine output should be monitored.
It is prudent to involve an anesthesiologist in the patient’s care, because if labor does not progress rapidly as in cases like feto-pelvic disproportion, fetal malpresentation, or a prior classical cesarean delivery, it will be necessary to conduct a cesarean delivery to avoid worsening of the coagulopathy.
Bleeding from surgical incisions in the presence of DIC may be difficult to control, and it is equally important to stabilize the patient and to correct any coagulation derangement occuring during surgery. The patient should be monitored closely after delivery, with particular attention paid to her vital signs, amount of blood loss, and urine output. In addition, the uterus should be observed closely to ensure that it remains contracted and is not increasing in size.
Immediate delivery is indicated in cases of abruption at term or near term with a live fetus. In such cases the main question is whether vaginal delivery can be achieved without fetal or maternal death or severe morbidity. In cases where there is evidence of fetal compromise, delivery is not imminent and cesarean delivery should be performed promptly, because total placental detachment could occur without warning.

Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.

Fetal position and presentation is best evaluated by Leopold’s manoeuvre. It will determine which part of the foetus is in the uterine fundus.
Cullen’s sign is found in ruptured ectopic pregnancy characterised by bruising and oedema of the periumbilical region.
Mauriceau-Smelli-Veit manoeuvre is done during a breech delivery.

During pelvimetry, the shape of the pubic arch is usually examined. It helps in determining the outcome of the type of fetal delivery.

Expected date of delivery (EDD) is a calculated from the first day of the woman’s last menstrual period. If her periods are regular i.e., 28-day menstrual cycle, Naegele’s rule may be used. Naegele’s rule involves a simple calculation: add seven days to the first day of your LMP and then subtract three months. e.g. 30 June + 7 days = 7 July, minus 3 months = 7 April.

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.

Typically fetal movements become apparent by 18-20 weeks

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

The best antibiotic of choice for empirical treatment of a urinary tract infection (UTI) during pregnancy is cephalexin. Nitrofurantoin and amoxicillin-clavulanate are second and third in-line respectively.
Patients allergic to penicillin, which is manifested as a rash can also be safely treated with cephalexin. But cephalosporins are not recommended if the presentation of allergic reaction to penicillin was anaphylactic, instead they should be treated with nitrofurantoin.

NOTE– Asymptomatic bacteriuria, such as >10 to power of 5 colony count in urine culture of an asymptomatic woman in pregnancy, should best be treated with a one week course of antibiotics, followed by confirming the resolution of infection via a urine culture repeated 48 hours after the completion of treatment.

Amoxicillin without clavulanate is recommended only in cases were the susceptibility of the organism is proven.

Macrolides like clarithromycin are usually not recommended for the treatment of UTI.

Aminoglycosides are coming under category D drugs should be avoided during pregnancy, unless there is a severe indication of gram negative sepsis.

Tetracycline, due to their potential teratogenic effects, are contraindicated in pregnancy.

The gestational sac can be visualized from as early as 4–5 weeks of gestation and the yolk sac at about 5 weeks (Figure 6.3). The embryo can be observed and measured at 5–6 weeks gestation.

Gardnerella vaginalis is one of the bacteria implicated in the development of bacterial vaginosis , many women (>50%) with this vaginal infection have no signs or symptoms, when these are present they are most often :
Vaginal discharge, grey, white or green, with a strong unpleasant odour
Strong vaginal odour and fishy smell after sex
Vaginal itching
Burning during urination
Vaginal bleeding after sex
Gardnerella vaginalis can also be responsible for serious infections (sepsis, wound infections) in locations other than those associated with the genital tract or obstetrics, these cases are very rare but have been reported, including in men.

Mycoplasma Hominis is one of the organisms involved in the pathogenesis of BV but it appears normal on wet mount.

Candida presents with white cottage cheese like discharge.

Chlamydia is not seen on wet mount and produces clear vaginal discharge.

Trichomonas shows clue cells on wet mount.

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.

This patient presents with secondary amenorrhea, a condition diagnosed in patients with – 3 months of absence of menstruation when they had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea- This differs from primary amenorrhea, which is defined as absence of menstrual periods in a female by the age 16 when she has other secondary sexual characteristics or absence of menstrual periods by the age of 14 when she does not have any other secondary sexual characteristics.

In female patients of child-bearing age, the initial test in evaluating secondary amenorrhea is the pregnancy test. This test has been done in this patient and it is negative- The next step in evaluation in this patient should be serum TSH and prolactin level measurements. Thyroid disease and pituitary pathologies are some of the most common causes of secondary amenorrhea- If these tests were to be found normal, the progesterone challenge test would be the following test as this allows evaluation whether amenorrhea is due to progesterone deficiency in a patient with normal oestrogen levels.

→ Order FSH and LH level is incorrect. These studies are done if the progesterone withdrawal test is negative but the oestrogen-progesterone challenge test is positive; however, the patient should first have TSH and prolactin level measured; the progesterone withdrawal test is only done if TSH and prolactin are normal.
→ Order a progesterone withdrawal test is incorrect. As explained above, this test is ordered if TSH and prolactin levels are normal in a patient suspected to have secondary amenorrhea.
→ Order pelvic ultrasound is incorrect. This study is more important in primary amenorrhea evaluation as it can help confirm the presence or absence of a uterus. This patient who has had menstrual periods before does certainly have a uterus.
→ Order brain MRI is incorrect. Given how expensive this study is, it should not be done before prolactin levels are found to be significantly high, raising suspicion of a pituitary pathology.

Amniotic fluid volume begins to increase rapidly in the second and third trimester as the fetal kidneys continue to develop. By 35 weeks gestation the amniotic fluid volume reaches a maximum average of about 800 ml after which it decreases slightly to term.

Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement.

Most women lose about 35-40 ml of blood on average during each menstrual cycle. The maximum amount of blood loss is 80 ml after which blood loss of more than 80 ml is defined as heavy menstrual bleeding, formerly known as menorrhagia.

Tetracycline is classified as a broad spectrum antibiotic. It is a bacteriostatic inhibitor of protein synthesis acting at the ribosomal level. Tetracycline binds to the 30s ribosomal subunit preventing the binding of the aminoacidic charged T-RNA to the ribosome-mRNA complex.

Condylomas are warty neoplasms of the vulvar area. The most common type are condyloma acuminatum which occur due to HPV 6 or 11. Condyloma latum are also known as secondary syphilis are less common. Both of these are sexually transmitted.

Stages of Syphilis:
– Primary 3-90 days
Chancre and lymphadenopathy
– Secondary 4-10 weeks
Widespread rash typically affecting hands and soles of feet.
Wart lesions (condyloma latum) of mucus membranes
– Latent Early <1 yr. after secondary stage
– Late >2 yr. after secondary stage
Asymptomatic
– Tertiary 3+ years after primary infection
Gummas or
Neurosyphilis or
Cardiovascular syphilis

There are no interactions between the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone injections or levonorgestrel implants and the AEDs valproic acid (sodium valproate), vigabatrin, lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide, ethosuximide and the benzodiazepines. So she can use COCP along with Sodium valproate.

Congenital Adrenal Hyperplasia leads to the virilization of the foetus. It occurs due to an enzyme deficiency in the corticosteroid production pathway i.e. 21-hydroxylase which converts progesterone to deoxycorticosterone. The reduced levels of corticosteroids results in the negative feedback loop that leads to adrenal hyperplasia.

NICE guidelines (CG74) advise the following regarding postoperative wound management Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus. Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection

Gestational trophoblastic disorder is abnormal conception that is characterised by swollen and oedematous villi with proliferation of the trophoblasts. In a complete mole there is absence of fetal tissue, there is diffuse proliferation of trophoblastic tissue around hydropic villi and on USG it appears as a bunch of grapes or snow storm appearance.

History of heavy menstrual bleeding and amenorrhoea favour the diagnosis of a fibroid uterus. All the given responses are causes for subfertility. Ectopic pregnancy presents with abdominal pain has an acute presentation. Endometriosis and adenomyosis usually don’t present with amenorrhoea or heavy bleeding respectively. PID presents with chronic pelvic pain and is not related to menstruation.

Barr body is an inactive and non functioning X chromosome found in female somatic cells and is presents with a rim around the nucleus