Fibroadenoma usually occurs in younger women. These non-tender masses can be removed for aesthetic purposes. Breast cysts are common shifting masses inside the breast tissue more common in women over the age of 35.

Above mentioned patient presented with symptoms of premature rupture of membranes (PROM) which refers to membrane rupture before the onset of uterine contractions.

A sudden gush of clear or pale yellow fluid from the vagina is the classic clinical presentation of premature rupture of membranes. Along with this the patient also developed signs of infection like fever, tachycardia and sweating which is suggestive of chorioamnionitis.

Vaginal examination is never performed in patients with premature rupture of membrane, instead a speculum examination is the usually preferred method which will show fluid in the posterior fornix.

The following are the steps in management of premature rupture of membrane:
– Admitting the patient to hospital.
– Take a vaginal
ervical smears.
– Measure and monitor both white cell count and C- reactive protein levels.
– Continue pregnancy if there is no evidence of infection or fetal distress.
– In presence of any signs of infection or if CTG showing fetal distress it is advisable to induce labour.
– Corticosteroids must be administered if delivery is prior to 34 weeks of gestation.
– Give antibiotics as prevention and for treatment of infection.

In high-risk pregnancies, continuous monitoring of foetal heart rate is considered mandatory.

However, in low-risk pregnancies, cardiotocograph (CTG) monitoring provides no benefits over intermittent auscultation.

A significant issue with CTG monitoring is that apparent abnormalities are identified that usually have minimal clinical significance, but can prompt the use of several obstetric interventions such as instrumental deliveries and Caesarean section. In low risk patients, such interventions may not even be required.

CTG monitoring has not been shown to reduce the incidence of cerebral palsy or other neonatal developmental abnormalities, nor does it accurately predict previous foetal oxygenation status unless the CTG is significantly abnormal when it is first connected.

Similarly, CTG cannot accurately predict current foetal oxygenation unless the readings are severely abnormal.

Therefore, there is no evidence to support routine admission CTG (correct answer).

Thyroid disease is the second most common endocrine disorder after diabetes in pregnancy. Thyroid disease poses a substantial challenge on the physiology of pregnant women and has significant maternal and fetal implications. Research shows during pregnancy, the size of the thyroid gland increases by 10% in countries with adequate iodine stores and by approximately 20% to 40% in countries with iodine deficiency. During pregnancy, thyroid hormone production increases by around 50% along with a similar increase in total daily iodine requirements.

The different changes occurring in thyroid physiology are as follow:
– An increase in serum thyroxine-binding globulin (TBG) leading to an increase in the total T4 and total T3 concentrations
– Stimulation of the thyrotropin (TSH) receptor by human chorionic gonadotropin (hCG) which increases thyroid hormone production and subsequently reduces serum TSH concentration.

Therefore, compared to the non-pregnant state, women tend to have lower serum TSH concentrations during pregnancy.
The need to adjust levothyroxine dose manifests itself as early as at 4-8 weeks of gestation, therefore justifying the adjustment of levothyroxine replacement to ensure that maternal euthyroidism is maintained during early gestation. Most of well-controlled hypothyroid pregnant women need increased dosage of thyroid hormone after pregnancy.

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.

Immediately after birth the liver is deprived of the large flow of blood supplied during foetal development via the umbilical vein and portal sinus. Simultaneously the blood pressure in the portal sinus, previously as high as in the umbilical vein, falls.

The ‘Blueberry muffin’ rash is a descriptor for the rash seen in Congenital Rubella Syndrome. A similar petechial rash may also occur in CMV infection but shouldn’t be termed ‘blueberry muffin’

This question assesses critical clinical knowledge, as this information must be presented to a patient prior to an amniocentesis to ensure that she has given her informed permission for the treatment.
Amniocentesis is most typically used for genetic counselling in the second trimester of pregnancy. Another option is to do a chorion-villus biopsy (CVB) between 10 and 11 weeks of pregnancy.
The chances of miscarriage after both operations are roughly 1 in 200 for amniocentesis and 1 in 100 for CVB, according to most experts.
The significance of this question is that professionals must be able to weigh the procedure’s danger against the risk of the sickness they are trying to identify.

Abnormal uterine bleeding is a relatively common disorder which may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.

Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problem or for older women. Oestrogen would only increase the problem, which is usually due to anovulation with prolonged oestrogen secretion, producing a hypertrophic endometrium.

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity.

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.

Oestradiol is the predominant form of oestrogen during the reproductive life of a female. The estrogenic potency of oestradiol is 12 times more than estrone and 80 times that of estriol.

Fetal Blood Sampling (FBS) should only be performed when the cervix is >3cm dilated.

Indications for FBS:
1. Pathological CTG in labour
2. Suspected acidosis in labour

Contraindications to FBS
– Maternal infection e.g. HIV, HSV and Hepatitis
– Known fetal coagulopathy
– Prematurity (< 34 weeks gestation)
– Acute fetal compromise

Interpretation of FBS results:
pH >7.25 = Normal -Repeat in 1 hour if CTG remains abnormal
7.21 to 7.24 = Borderline – Repeat in 30 minutes
<7.20 = Abnormal - Consider delivery

Major vessel injury is the most important potential complication when undertaking laparoscopy. It’s incidence is 0.2/1000. Bowel Injury is more common at 0.4/1000

Gonorrhoea is a diplococcus bacteria known to infect the female genital tract. The bacteria is sexually transmitted and can cause an ascending infection in the uterus and fallopian tubes. According to the BASHH guidelines (British Association for Sexual Health and HIV), indication for therapy include confirmation of intracellular diplococci on microscopy or a confirmed positive NAAT. Treatment of gonorrhoea in pregnancy is as follows: Ceftriaxone 1g intramuscularly as a single dose with azithromycin 2g oral as a single dose. Pregnant individuals are not to be treated with quinolones or tetracyclines.

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)

Activation of Antithrombin III and inactivation of factor Xa is the primary mechanism of action of Heparin.

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.

The uterine and vaginal arteries branch from the internal iliac artery. The ovarian artery branches direct from the aorta.

The juxtaglomerular apparatus is the main site for the production of renin. It plays an important role in the regulation of the blood pressure. These structures are mainly located in the cortex of the kidneys.

The placenta produces Estriol from 16-OH DHEAS. Estriol is the major oestrogen (oestrogen) of pregnancy and the placenta is the primary site of production. Pregnenolone is synthesised by the placenta from cholesterol and this is converted to dehydroepiandrosterone (DHEA) in the fetal adrenal gland

Multiple epidemiological risk factors have been identified in patients who have adenocarcinoma of the endometrium.
– Endogenous factors
– Obesity
– Nulliparity
– An individual who has had a late menopause (aged >52 y)
– Unopposed oestrogen
– Tamoxifen
– Family history
– Individuals with a family history of endometrial cancer appear to be at increased risk.

Obligate anaerobes are a group of bacteria that cannot survive in an oxygen-rich environment. In the body, they are usually found on mucosal membranes such as that of the lower gastrointestinal system, or the vagina. Infection with these organisms is usually suprative and causes abscesses. Examples of gram-negative anaerobes include Bacteroides, Fusobacterium and Prevotella, while gram-positive anaerobes include Actinomyces and Clostridia. Staphylococcus and Streptococcus are both gram-positive facultative anaerobes.

Common Risk factors for Ovarian torsion are presence of an ovarian mass, women who are in their reproductive age and history of infertility treatment with ovulation induction.
Common clinical presentations include sudden onset of unilateral pelvic pain along with nausea & vomiting and presence of a palpable adnexal mass. An adnexal mass with absent Doppler flow to ovary can be noted in ultrasound.
Laparoscopy with detorsion, ovarian cystectomy and oophorectomy if necrosis or malignancy is found are the common treatment options.

Acute lower abdominal pain in a nonpregnant women can have various causes including pathologies of the gastrointestinal, gynecologic, or urologic systems due to the close proximity of these structures. All of these cases have classic presentations which help to characterize the disease process and thereby to differentiate the diagnosis.

In the given case, patient presents with right lower quadrant pain which is classic for ovarian torsion, occurring due to rotation of the ovary around the infundibulopelvic ligament, causing ovarian vessel occlusion.  Although ovarian torsion can occur in any women in their reproductive-age, is seen more commonly in those with a history of ovarian cysts (eg, hemorrhagic cyst) or masses (eg, mature cystic teratoma) because of the greater size and density of the ovary which makes it prone to rotation and subsequent torsion. Patients will initially have intermittent pain associated with activity, as in this patient, due to partial ovarian torsion, this initial pain resolves when the adnexa spontaneously untwists and blood flow returns. When this progresses to complete ovarian torsion, patients typically develop sudden-onset, severe, nonradiating pain due to persistent ischemia, which is often associated with nausea and vomiting.

Ovarian torsion can be clinically diagnosed, but a Doppler ultrasound is performed to evaluate ovarian blood flow and also to confirm the diagnosis. Surgical detorsion to prevent ovarian necrosis and cystectomy/oophorectomy are the usual treatment options.

Any association of urinary symptoms will help to establish a urologic cause of acute right lower quadrant pain like pyelonephritis, nephrolithiasis, etc.  However, patients with urologic conditions typically presents with suprapubic or flank pain which radiates to the right lower quadrant, making this diagnosis less likely in the given case.

A family history of malignancy usually does not aid in the diagnosis of acute lower abdominal pain. Although some ovarian cancers are inherited, patients with ovarian cancer typically have a chronic, indolent course with associated weight loss, early satiety, and abdominal distension.

Having multiple sexual partners is considered a risk factor for sexually transmitted infections and pelvic inflammatory disease, which can be a cause for lower abdominal pain. However, patients will typically have fever, constant and diffused pelvic pain along with rebound and guarding.

Recent sick contacts are a risk factor for gastroenteritis, which can present with nausea, vomiting and abdominal pain. However, in this case patient will typically have diffuse, cramping abdominal pain which will worsen gradually; along with persistent vomiting and diarrhea.

Ovarian torsion typically causes intermittent lower abdominal pain followed by sudden-onset of severe, nonradiating unilateral pain with associated nausea and vomiting. Ovarian torsion can occur in women in their reproductive-age, particularly those with a history of ovarian cysts.

Breast milk contains around 4% fat, 7% sugar and 1% proteins. The rest is water and minerals.

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 75g 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.

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

There is an increase risk of developing carcinoma of the uterus, if the endometrium shows hyperplasia with atypia. The standard surgery is total hysterectomy with bilateral salpingectomy which can be performed abdominally or laparoscopically If the disease is grade 1-2 and less than 1B i.e. less than 50% invasion of the uterine body.

Serum prolactin levels are increased during suckling. Some other conditions in which serum prolactin is increased consist of: prolactin secreting brain tumours, anti psychotic drugs and hypothyroidism. It can also be increased in pregnancy, nipple stimulation and stress.

Detrusor contraction is via Parasympathetic innervation of pelvic splanchnic nerves (S2-4). This also causes relaxation of the internal urethral sphincter Note contraction and relaxation of the external urethral sphincter is under somatic control.