Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.

Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia.

Menorrhagia in a 45-year-old woman is most likely caused by an ovulation issue, most likely anovulatory cycles, particularly if the periods have grown irregular.

Endometrial carcinoma is a rare cause of menorrhagia that usually occurs after menopause.

Menorrhagia can be caused by fibroids, endometrial polyps, and adenomyosis, although the cycles are normally regular, and a dramatic change from normal cycles six months prior would be exceptional.
If fibroids or adenomyosis are the source of the menorrhagia, the uterus is usually enlarged.

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.

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.

The 1st commonly presents as cephalic. Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

The ovarian artery takes its origin directly from the aorta. While the uterine and the vaginal arteries are all branches of the internal iliac artery.

Significant proteinuria = urinary protein:creatinine ratio >30 mg/mmol or 24-hour urine collection result shows greater than 300 mg protein

Thee good news in regard to incontinence after childbirth is that there are many treatment options. Some common treatment options are listed below.

Food and drinks such as coffee, citrus, spicy foods and soda can all irritate the bladder. Cutting back on or eliminating these foods may help improve incontinence symptoms. Keeping weight within a healthy BMI range, and/or focusing on losing pregnancy weight, can also help with bladder control.

Kegels strengthen the pelvic floor, giving more control over urinary urges. Pelvic floor physical therapy can also help build muscle memory and strength. The abdominal muscles, hip muscles and pelvic floor muscles work together when a woman performs strengthening exercises like Kegels. Physical therapists identify areas of weakness in those muscle groups to help a woman build a strong core and pelvic floor.

The bladder is a muscle that should be regularly strengthened. Scheduling urination times and then gradually increasing the amount of time in between urination can increase bladder strength.

Percutaneous tibial nerve stimulation is a nonsurgical treatment for overactive bladder and a form of neuromodulation therapy. During PTNS treatments, a doctor places a slim needle in the ankle where the tibial nerve is located. The needle delivers electrical impulses to the tibial nerve, which sends signals to the sacral nerves in the spine that control bladder and pelvic floor function. Over time, these pulses block nerve signals that are not working properly to lessen urinary incontinence symptoms.

Evaluating lifestyle factors. Excessive coughing due to smoking or being overweight can put unnecessary strain on the pelvic floor muscles. Certain drugs such as antidepressants and antihistamines can also have an impact on urinary incontinence.
Pessary. A pessary is a device inserted into the vagina to provide support for vaginal tissues, in turn, aiding in bladder incontinence.

Surgical treatment options can help support the pelvic floor and may be recommended for women who have completed childbearing and have not had success with conservative therapy.

Perineal tears are common at the time of child birth. First degree perineal laceration means that the wound is so small that it doesn’t require any stitches and usually heals on its own. 2nd degree means that skin and smooth muscles are both torn. 3rd degree tear means that the tear is beyond the perineal muscles and the muscles surrounding the anal canal, while in 4th degree, the perineal tear goes through the anal sphincter up to the rectum.

The progestogen-only pill (POP) is a contraceptive option for women who have high blood pressure either induced by use of combined oral pills or due to other causes; as long as it is well controlled and monitored. Combined oral contraception (COC) and Depo-Provera have been implicated in increased cardiovascular risk following use. High blood pressure has been theorized to be the critical path that leads to this increased risk. POP is the recommended method for women who are at risk of coronary heart disease due to presence of risk factors like hypertension.

Stopping OCP will risk in the patient getting pregnant. Cessation of oestrogen usually reverses the blood pressure back to normal, Hence, all other options are incorrect.

Genital herpes can be asymptomatic or have mild symptoms that go unrecognized. When symptoms occur, genital herpes is characterised by one or more genital or anal blisters or ulcers. Additionally, symptoms of a new infection often include fever, body aches and swollen lymph nodes.

HSV-2 is mainly transmitted during sex through contact with genital or anal surfaces, skin, sores or fluids of someone infected with the virus. HSV-2 can be transmitted even if the skin looks normal and is often transmitted in the absence of symptoms.

In rare circumstances, herpes (HSV-1 and HSV-2) can be transmitted from mother to child during delivery, causing neonatal herpes. Neonatal herpes can occur when an infant is exposed to HSV during delivery. Neonatal herpes is rare, occurring in an estimated 10 out of every 100 000 births globally. However, it is a serious condition that can lead to lasting neurologic disability or death. The risk for neonatal herpes is greatest when a mother acquires HSV for the first time in late pregnancy.

When there are about 12-32 blastomeres, the developing human is referred to as morula. It enters the uterine cavity around the 4th day after fertilization.

P wave = Atrial depolarisation
QRS complex = Ventricular depolarisation
T wave = Ventricular repolarisation
U wave = repolarisation of the interventricular septum

Trichomoniasis is a common sexually transmitted infection caused by a parasite. In women, trichomoniasis can cause a foul-smelling vaginal discharge which might be white, grey, yellow or green, genital itching and painful urination.

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.

The round ligament is a band of fibromuscular connective tissue attached to the cornua of the uterus, near the attachment of the ovaries. On each side of the body, the ligament exits the pelvis through the deep inguinal ring, travels through the inguinal canal and enters the labia majora where its fibres terminate at the mons pubis. It is also important to know the embryological origins of the round ligament from the gubernaculum.

Ovulation occurs in the mid stage of the menstrual cycle, usually 36 hours after the LH surge. It is this LH surge which is necessary for the ovulation to occur.

Although acyclovir should be given, this patient is in the 3rd trimester so the course should continue until delivery. Dose will be 400mg TDS unless disseminated disease. If this is a primary HSV infection (This should be confirmed by lesion swabs to confirm HSV infection and bloods to check no antibody response i.e. evidence previous infection) then C-section is indicated.

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.

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.

Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

Miscarriage rates:
20-24 – 9%
25-29 – 11%
30-34 – 15%
35-39 – 25%
40-44 – 51%
>45 – 75%

Anticoagulant therapy is the standard treatment for deep vein thrombosis (DVT) but is mostly used in non-pregnant patients. In pregnancy, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are commonly used. Warfarin therapy is generally avoided in pregnancy because of its fetal toxicity.

Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy.

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. The intermittent vaginal bleeding and the requirement for manual removal of the placenta suggest endometritis as the most possible diagnosis.

It is classified under type II hypersensitivity reaction. Antibodies are formed against the rhesus antigen i.e. D antigen. Hence when the Antibody reacts with the antigen on the RBC it results in activation of the complement cascade leading to lysis.

The substructures of the nephrons are mainly located within the cortex. The JGA sits next to the glomerulus in the cortex (click on the magnifying glass of the image to see the arrangement). They play an important role in blood pressure homeostasis as the juxtaglomerular cells produce renin. The descending and ascending limbs of the loop of Henle and collecting ducts have sections within both the cortex and medulla

Absolute contraindications to OCs include breast cancer, history of deep venous thrombosis or pulmonary embolism, active liver disease, use of rifampicin, familial hyperlipidaemia, previous arterial thrombosis, and pregnancy, while relative contraindications include smoking, age over 35, hypertension, breastfeeding, and irregular spontaneous menstruation.

Institute of Medicine Weight Gain Recommendations for Pregnancy: Recommends a gestational weight gain of 16.8–24.5 kg (37–54 lb) for women of normal weight, 14.1–22.7 kg (31–50 lb) for overweight women, and 11.3–19.1 kg (25–42 lb) for obese women.

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

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

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