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.

Radiotherapy works on the principle of ionisation. In particularly that of water leading to the formation of free radicals, these radicals are highly reactive and they react with the DNA leading to damage and cell death.

At 12 weeks gestation the fundus is expected to be palpable above the pubis symphysis and it is expected to be felt at the level of umbilicus by 20 weeks. Though the uterine fundus stands in between from 12 and 20 weeks, the height of the fundus in centimeters is equivalent to the weeks of pregnancy after 20 weeks.

For 14-week pregnant uterus a fundal height of 18cm is definitely large and dating errors is considered as the most common cause for such a discrepancy. Hence, it is better to perform an ultrasound scan for more accurately estimating the gestational age. Also if the case is not a simple dating error, ultrasonography can provide definitive additional information about other possible conditions such as polyhydramnios, multiple gestation, etc that might have led to a large-for-date uterus.

A large-for-gestational-age uterus are most commonly found in conditions like:
– Dating errors which is the most common cause
– Twin pregnancy
– Gestational diabetes
– Polyhydramnios
– Gestational trophoblastic disease, also known as molar pregnancy

The female bony pelvis is larger, broader and more of a funnel shape. The inlet is larger and oval in shape and the sides of the female pelvis are wider apart.

As the most likely diagnosis, this woman meets diagnostic criteria for premenstrual syndrome (PMS).
Affective and physical symptoms that begin one week before menstruation and end four days after menstrual flow begins are diagnostic criteria for premenstrual syndrome. The symptoms must be present for at least three menstrual cycles and must not occur during the preovulatory period.
It’s critical to note that these symptoms are not caused by any medical or psychological condition, medications, drugs, or alcohol.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent tears, and a lack of interest in daily activities. To put it another way, emotional impairment is the most prominent trait.

This woman does not meet the diagnostic criteria for PMDD because she only has psychological symptoms of irritation and anxiety, as well as physical symptoms of headache and breast soreness (five symptoms).

PMDD diagnostic criteria include:
Symptoms and their timing
A) At least 5 symptoms must be present in the final week before menses, improve within a few days after menses, and become mild or non-existent in the week after menses in the majority of menstrual cycles.
Symptoms
B) At least one of the symptoms listed below must be present:
1) Affective lability that is noticeable (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
2) Excessive irritation, wrath, or interpersonal conflicts
3) Depressed mood, hopelessness, and self-depreciating thoughts
4) Severe anxiety, tension, and/or a sense of being tense or on edge
C) In addition to the symptoms listed in criterion B, one (or more) of the following symptoms must also be present to reach a total of five symptoms.
1) Loss of enthusiasm for customary activities
2) Subjective concentration problems
3) Lethargy, fatigability, or a noticeable lack of energy
4) Significant changes in appetite, such as binge eating or specific food desires
5) Insomnia or hypersomnia
6) A feeling of being overwhelmed or powerless
7) Physical signs and symptoms include breast discomfort or swelling, joint or muscle pain, bloating, or weight gain.
Severity
D)The symptoms are linked to clinically substantial distress or interfere with employment, school, regular social activities, or interpersonal relationships.
E) Think about other mental illnesses. The disturbance isn’t only a sign of another disorder, like major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
Confirmation of the condition
F)Prospective daily ratings throughout at least two symptomatic cycles should be used to confirm Criterion A. (although a provisional diagnosis may be made prior to this confirmation)
Other medical explanations are ruled out.
G) The symptoms aren’t caused by the physiological consequences of a substance (e.g., drug misuse, medication, or other treatment) or a medical condition (e.g., hyperthyroidism).
The severity of the symptoms cannot be explained by normal menstrual physiology.
Generalized anxiety disorder and depression are improbable diagnoses because these symptoms are temporally tied to menstrual cycles.

This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).

When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.

Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.

The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.

The pudendal nerve has its origins form S2, S3 and S4 spinal segments. It provides sensation to the clitoris and labia along with the ilioinguinal nerve.

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

With the high level of sensitivity and specificity of current tests to measure hCG in serum and urine, pregnancy can now be diagnosed before the time of the first missed menstrual period- For current serum hCG assays, the low threshold for detection is 10-25 IU/L, while for urine assays it is 25-50 IU/L, which corresponds to approximately the seventh day after conception. Because the levels of hCG in the blood and urine are very similar, the tests are equivalent. Urine testing may reveal a positive result as early as 3-4 days after implantation. By the time of the expected menstrual period, the test will be positive 98% of the time- If a test is negative more than 1 week after the expected time of the menstrual period, it is almost certain the patient is not pregnant. To cover these rare instances where a woman has a low hCG and conceived later than expected, the test should be repeated in 1 week for a definitive result.

Since ectopic pregnancy is not a life-threatening problem for the mother until 2 months after conception, a patient with a negative urine hCG does not require ultrasonography to exclude ectopic pregnancy. Patients with a suspected ectopic pregnancy and a negative urine hCG should be followed closely, as early laparoscopic intervention can improve the chances of future fertility.

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.

Mucinous tumours are cystic masses which are indistinguishable from the serous tumours on gross examination except by its contents. On histology it is lined with mucin producing epithelium – mucin vacuoles whereas serous tumours have psammoma bodies. Malignant tumours are characterised by the presence of architectural complexity, cellular stratification, stromal invasion and cytological atypia.

Sertoli cells contain receptors for FSH. In response to this Sertoli cells synthesize inhibin, androgen binding proteins and anti Mullerian hormone all which are connected to the reproduction cycle.

This woman has experienced a septic abortion. Therefore the first step is commencement of intensive antibiotic treatment as soon as cervical swabs have been taken.

The next step is evacuation of the uterus. Curettage can be performed after a few hours, to extract any remaining infected products of conception from the uterine cavity.

The choice of antibiotics depends on the most likely microorganism involved. Therefore, prior to commencing any other procedure, it is vital to take cervical swabs for microscopic examination to guide further antibiotic therapy (correct answer).

If curettage is performed immediately there is a risk that the infection would spread.

However, if Clostridium welchii infection is suspected from the cervical smear (particularly if encapsulation of the microorganisms is present), then curettage should be performed immediately along with commencing antibiotic treatment.

Curettage can be delayed for up to 12-24 hours if other microorganisms are suspected; unless a significant increase in bleeding occurs.

Ergometrine is not essential as an immediate treatment measure as the patient is not bleeding heavily and reports that her bleeding has decreased. However, ergometrine is commonly given when curettage is performed.

This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day.  Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.

All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.

In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.

Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.

In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.

Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point).  This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.

Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.

Endometrial cancer is one of the most common gynaecological malignancies present in postmenopausal women, with a peak incidence between the ages of 60-89. Factors associated with endometrial cancer include obesity, hypertension and diabetes. Full staging for endometrial cancer is surgical, including several other radiologic investigations. According to FIGO staging classifications:
Stage 1 indicates a tumour confined to the uterine body
Stage 2 indicates the invasion of the cervical stroma
Stage 3 indicates local and regional spread, where the tumour invades the serosa in stage 3A, spreads to the vagina and parametrium in stage 3B, and metastasizes to the pelvic or para-aortic lymph nodes in stage 3C.
Stage 4 indicates tumour invasion on the bladder or bowel mucosa, or distant metastasis.

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.

In an ECG the P wave represents atrial depolarization. The QRS complex represents the ventricular depolarization, T waves represent ventricular repolarization and the U wave represents repolarization of the interventricular septum.

In a person who is infected by streptococcus (Group B) should be started on benzylpenicillin as soon as possible. In case of allergy vancomycin should be started at 1g every 12 hours. Tetracyclines should be avoided in pregnancy.

An endometrioma, also known as a chocolate cyst is a benign ovarian cyst that occurs as a result of the trapping of endometriosis tissue inside the ovary. The findings on transvaginal ultrasound are often a unilocular cyst, with ground glass echogenicity due to haemorrhage. Other benign masses that can be evaluated using transvaginal ultrasound are functional cysts, serous and mucinous cystadenomas and mature teratomas.

Phosphate and ammonia are the major urinary buffers

The best next step in her management is a colposcopy.

Patients diagnosed with high-grade lesions (CIN 2 or 3) or adenocarcinoma in situ (AIS) during pregnancy should undergo surveillance via colposcopy and age-based testing (cytology/HPV) every 12-24 weeks.

Cone biopsy and long loop excision of the transformation zone (LLETZ biopsy) are not recommended if the lesion extends up the canal and out of the vision of the colposcope.
It is not necessary to terminate the pregnancy.

Because repeat colposcopic examination during pregnancy offers all of the information needed, the repeat Pap smear is best done after the pregnancy has ended.

Unless colposcopy indicates aggressive cancer at an earlier time, the ultimate therapy required is usually not decided until the postpartum visit.

At the time of delivery, the most important signs of complete placental separation are lengthening of the umbilical cord, per vaginal bleeding and change in shape of uterus from discoid to globular shape. The uterus contracts in size and rises upward.

Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

Nerve Supply: L5 to S2 via Nerve to Piriformis
Origin: Sacrum
Insertion: Greater trochanter
Action: External rotation of hip
Blood Supply: Superior and Inferior gluteal arteries and lateral sacral arteries

Following an abortion or miscarriage, combined oral contraceptive pills should be started immediately.

The neck of the bladder is surrounded by the internal sphincter. It is supplied by the sympathetic and parasympathetic nerves of the splanchnic nerve. Parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. It Is predominantly by the parasympathetic nerves S2-S4. Relaxation of the bladder is caused by inhibiting the sacral parasympathetic preganglionic neurons and exciting the lumbar sympathetic preganglionic neurons. Remember SYMPATHETIC is for STORAGE and PARASYMPATHETIC is for PEEING.

A 20 weeks pregnant patient has developed goitre along with thyrotoxicosis, where the diagnosis of thyrotoxicosis has already been established.
Ultrasound of the thyroid and a radioisotope scan to differentiate between “hot” and “cold” nodules are the confirming investigations for goitre. A nodule composed of cells that do not make thyroid hormone and the nodule which produces too much thyroid hormone are respectively called as cold and “hot” nodules.

Due to the risk of fetal uptake of the isotope which leads to the damage of fetal thyroid, radioisotope or radionuclide Technetium uptake scan is contraindicated in pregnancy.

Fine needle aspiration cytology is required to establish a histopathological diagnosis in case of all cold nodules.

So ultrasound of the thyroid gland is the mandatory investigation to be done in this case as it will show diffuse enlargement, characteristic of the autoimmune disease, or multinodularity, which is suggestive of autonomous multinodular goitre.

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

A screening blood test for the infectious diseases HIV, Syphilis, Rubella, Toxoplasmosis and Hepatitis B is offered to all pregnant females so as to reduce the chances of transmission to the neonate.

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.