TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

A variety of changes in the cardiovascular system occur during normal pregnancy, including increases in cardiac output, arterial compliance, extracellular fluid volume and decreases in blood pressure (BP) and total peripheral resistance.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

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

Trichomoniasis is considered a sexually transmitted infection found both in men and women caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour.

For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy.

The recommended treatment for t. vaginalis during pregnancy and breastfeeding is 400-500mg of metronidazole twice daily for 5 -7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated, and screening for other STIs should be carried out.

An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

The earliest fetal heart rate detected transvaginally was at 6 weeks 0 days of gestation compared with 7 weeks 0 days transabdominally. The transvaginal Doppler method was also more successful in detecting the fetal heart rate in women with a retroverted uterus (p < or = 0.01).

The best answer is Polycystic Ovarian Syndrome (PCOS), supported by amenorrhea, obesity and acne. High insulin levels are indicative of PCOS and exclude Cushing syndrome (as this is associated with low insulin levels).

Congenital cytomegalovirus infections are the most common cause of sensorineural hearing loss in babies. Cytomegalovirus infection during the perinatal period can be transferred to the foetus especially if the primary infection is during pregnancy. Babies born with congenital CMV are either symptomatic or develop symptoms later in life. Some of the features of CMV infection include sensorineural hearing loss, visual impairment, cerebral palsy, microcephaly and seizures. Other causes of infective congenital sensorineural hearing loss include: Rubella, HIV, Herpes Simplex Virus, Measles, Varicella Zoster virus, Mumps and West Nile Virus.

Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.

Miscarriage is a pregnancy that ends spontaneously before the foetus reaches the age of viability i.e. before 24 weeks of gestation. In a threatened miscarriage the USG findings are of a foetus present in the uterus and on speculum examination the cervical OS is closed, in an inevitable miscarriage the cervical OS is opened. In an incomplete miscarriage the uterus contains the retained products of conception and the cervical OS is open. complete miscarriage contains no retained products of conception and the cervix is closed as the bleeding as resolved.

Level I: Evidence obtained from at least one properly designed randomized controlled trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

The history is typical of Intrahepatic Cholestasis of Pregnancy, also known as obstetric cholestasis and prurigo gravidarum. It is characterised by itching without rash and abnormal LFTs beyond normal pregnancy ranges. Itching affects around 23% of pregnancies and can occur before biochemical changes.

Clotting factor problem. Some of the more common disorders of coagulation that occur during pregnancy are von Willebrand disease, common factor deficiencies, platelet disorders and as a result of anticoagulants.

The anterior aspect of the vulva (mons pubis, anterior labia) is supplied by derivatives of the lumbar plexus: the anterior labial nerves, derived from the
ilio-inguinal nerve, and the genital branch of the genitofemoral nerve.
The posterior aspect of the vulva is supplied by derivatives of the sacral plexus: the perineal branch of the posterior cutaneous nerve of the thigh laterally, and the pudendal nerve centrally.

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.

Causes of Hyperprolactinemia: Prolactinomas, Medication (phenothiazines, metoclopramide, risperidone, selective serotonin reuptake inhibitors, oestrogens, verapamil), Stress, Pregnancy, Hypothyroidism, Kidney disease, Chest trauma

The yolk sac increases in size up until the 10th week reaching a maximum diameter of 6mm in normal pregnancy. After the 10th week the yolk sac will gradually disappear. It is usually sonographically undetectable by 20 weeks. A yolk sac greater than 6mm diameter is suspicious of failed pregnancy.

Predisposing factors of preterm delivery include a short cervix (or if it shortens earlier than in the third trimester), urinary tract or sexually transmitted infections, open cervical os, and history of a previous premature delivery. Increased uterine size can also contribute to preterm delivery and is seen with cases of polyhydramnios, macrosomia and multiple pregnancies. The shorter the cervical length, the greater the risk of a premature birth.
In this case, the risk of bacterial vaginosis and candidiasis contributing to preterm delivery would be lower than if in the context of an open cervical os. However, the risk of premature delivery is significantly increased if it is found that the fetal fibronectin test is positive, even if the os is closed.

There are 2 treatment options: Spiramycin ASAP if foetus not infected or status of the foetus not known. This reduces risk of transplacental infection. This is continued until term, or until fetal infection is documented. Pyrimethamine, sulfadiazine and folic acid where fetal infection is known e.g. positive amniotic fluid PCR. Monitoring for haemotoxicity required. Pyrimethamine should be avoided in the 1st trimester as teratogenic

Oesophageal atresia/TE fistula may be suspected prenatally with ultrasound findings of polyhydramnios, absence of fluid in the stomach, small sized abdomen, or the presence of a dilated proximal oesophageal pouch. An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

Most carcinomas spread primarily via lymphatic invasion. Renal cell is the exception spreading via the bloodstream.

Retarded skeletal growth resulting in small for gestational age babies are the usual outcomes of an untreated vitamin D deficiency in pregnancy.

Symptoms associated with maternal vitamin D deficiency during pregnancy are:
– Hypocalcemia in newborn.
– Development of Rickets later in life.
– Defective tooth enamel.
– Small for gestational age due to its effect on skeletal growth
– Fetal convulsions or seizures due to hypocalcemia.

Meconium first appears in the fetal ilium at 10-16 weeks.

Thyroid function in pregnancy is altered in two ways; the circulating levels of the thyroid binding proteins are increased, resulting in an increase in the total circulating levels of thyroid hormones (but a slight fall in the free component).

CA-125 is the tumour marker specific for ovarian carcinoma.

Apoptosis is described as programmed cell death. The cell release certain proapoptotic mediators that regulate this cell death.

The endometrium is lined by columnar epithelium

Chorion villus sampling is an invasive procedure which aims to collect the rapidly dividing cells in the placenta. It is used for numerous reasons including detection of early pregnancy, viability of the foetus, singleton pregnancy, confirm gestation age and for prenatal diagnosis of the fetal chromosomal abnormalities including diagnosis of Down’s syndrome. However it hold a 2% chance of miscarriage during the procedure. Nuchal thickness and imaging are part of the combined test that must have been performed before.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

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.

Randomized control trials are the gold standard when it comes to assessing the treatment options or interventions in medicine. Since its introduction, RCT has questioned the validity of treatments such as oral hypoglycaemic agents, myocardial infarction hospitalization, varicose veins, toxicity and applicability of many preventive and therapeutic procedures. The basic steps include drawing up the protocol, selecting a study population, randomization, intervention, follow up and assessment of the outcome. Note if assessing prognosis or diagnostic tests Cohort and Cross Sectional Analysis are best.

With increasing maternal age, the risk of miscarriage increases. For women between the ages of 40-44, the miscarriage rates sit at about 50% and increases to over 75% for women 45 years and over. The miscarriage rate for women between the ages of 35-39 is 25%.

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.

Galactopoiesis and Lactogenesis are stimulated by Prolactin. Dopamine released under hypothalamic control inhibits Prolactin production. Note oestrogen and progesterone inhibit lactogenesis up until term.

A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.

In a postmenopausal woman, the ovaries should not be palpable; if they are, it should raise the concern that an ovarian malignancy is present. Before one would perform an operative evaluation, radiologic assessment should be done.

– Although this is an accepted regimen for oestrogen replacement therapy, the palpable ovaries need to be evaluated to rule out malignancy.
– Dual photon densitometry will give a reliable measure of bone density. Again, however, the palpable ovary is the first thing that needs to be worked up.
– Although surgical exploration may be warranted, initial workup of the adnexal mass should include an ultrasound along with tumour markers. A CT scan may also be warranted.

Cephalosporins are beta lactum drugs, like penicillin. They act by inhibiting the cross linkage of the peptidoglycan wall in bacteria.

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.

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.

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 WHO recommends that tocolytics can safely be used to prolong pregnancy for up to seven days. The tocolytic drugs are used to suppress contractions to allow for more favourable conditions in the case of preterm labour, such as transfer to a better-equipped health care facility with a neonatal intensive care unit, or for those who have not yet completed a full dose of corticosteroids. It is not however associated with better neonatal outcomes in the imminent delivery of preterms. Examples of tocolytics include calcium channel blockers, magnesium sulphate, and oxytocin antagonists.

Overflow incontinence typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying. Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia. When the bladder is very full, stress leakage can occur or low-amplitude bladder contractions can be triggered resulting in symptoms similar to stress or urgency incontinence.

Women with urgency incontinence experience the urge to void immediately preceding or accompanied by involuntary leakage of urine

Individuals with stress incontinence have involuntary leakage of urine that occurs with increases in intraabdominal pressure (e.g., with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction.

Cystic fibrosis is the most common fetal genetic disease in Caucasians and has an autosomal recessive inheritance. It is caused by an abnormal chloride channel due to a defect in the CFTR gene. Complications range from haemoptysis, respiratory failure, biliary cirrhosis, diabetes and male infertility. Men with CF are infertile in 98% of the cases due to failure of development of the vas deference.

Taking into consideration that she had only missed one pill and that they were going to be stopped the next day anyway, the rate of pregnancy would be low; hence all of the responses would be acceptable and effective. However, the most appropriate step would be to initiate her hormone-free interval starting from the time she missed her pill i.e. 11pm the night before. This would make tonight the 2nd lactose pill day and hence she should commence the next course of hormone pills on the 5 nights from tonight. In doing this, her hormone-free period would be the usual length of 7 days. Although the risk of pregnancy is low after missing only one pill, this opposite occurs when the missed pill causes a longer than normal hormone-free duration between the end of the current cycle and the starting of the subsequent one.

Pyelonephritis is the most common serious medical problem that complicates pregnancy. Infection is more common after midpregnancy, and is usually caused by bacteria ascending from the lower tract. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteraemia- A common finding is thermoregulatory instability, with very high spiking fevers sometimes followed by hypothermia- Almost 95% of women will be afebrile by 72 hours. However, it is common to see continued fever spikes up until that time- Thus, further evaluation is not indicated unless clinical improvement at 48-71 hours is lacking. If this is the case, the patient should be evaluated for urinary tract obstruction, urinary calculi and an intrarenal or perinephric abscess. Ultrasonography, plain radiography, and modified intravenous pyelography are all acceptable methods, depending on the clinical setting.

The changes seen in breast tissue with the menstrual cycle are accentuated during pregnancy. Deposition of fat around glandular tissue occurs, and the number of glandular ducts is increased by oestrogen, while progesterone and human placental lactogen (hPL) increase the number of gland alveoli. Prolactin is essential for the stimulation of milk secretion and during pregnancy prepares the alveoli for milk production. Although prolactin concentration increases throughout pregnancy, it does not then result in lactation since it is antagonized at an alveolar receptor level by oestrogen.

The Rhesus status of a mother is important in pregnancy and abortion. The exposure of an Rh-negative mother to Rh antigens from a positive foetus, will influence the development of anti-Rh antibodies. This may cause problems in subsequent pregnancies leading to haemolysis in the newborn. Rh Anti RhD- globulin is therefore given to non-sensitised Rh-negative mothers to prevent the formation of anti-Rh antibodies within 72 hours following abortion. Anti RhD globulin is not useful for already sensitized, or RhD positive mothers.

Fetal ultrasound scanning is considered an essential part of routine antenatal care with first trimester scans recommended for confirming viability, accurate estimation of gestational age and determining the number of foetuses. Fetal crown-rump length (CRL) is measured in early pregnancy primarily to determine the gestation age (GA) of a foetus and is most reliable between 9+0 to 13+6 weeks’ gestation, but not beyond.

The episiotomy is a technique originally designed to reduce the incidence of severe perineal tears (third and fourth-degree) during labour. The general idea is to make a controlled incision in the perineum, for enlargement of the vaginal orifice, to facilitate difficult deliveries.

Below is the classification scale for the definitions of vaginal tears:
First degree involves the vaginal mucosa and perineal skin with no underlying tissue involvement.
Second degree includes underlying subcutaneous tissue and perineal muscles.
Third degree is where the anal sphincter musculature is involved in the tear. The third-degree tear can be further broken down based on the total area of anal sphincter involvement.
Fourth degree is where the tear extends through the rectal muscle into rectal mucosa.

In most cases reported, puerperal hematomas arise due to bleeding lacerations related to operative deliveries or episiotomy, and in rare cases from spontaneous injury to a blood vessel in the absence of any laceration/incision of the surrounding tissue. Vulval, vaginal/paravaginal area and retroperitoneum are considered the most common locations for puerperal hematomas.

Most puerperal hematomas are diagnosed based on the presence of characteristic symptoms and physical examination findings:
VuIvar hematoma usually presents as a rapidly developing, severely painful, tense and compressible mass which is covered by skin of purplish discoloration. A vulvar hematoma can also be an extension of a vaginal hematoma which was dissected through a loose subcutaneous tissue into the vulva.
Vaginal hematomas often present with rectal pressure, were hemodynamic instability caused due to bleeding into the ischiorectal fossa and paravaginal space are the first signs and can result in hypovolemic shock. In these cases a large mass protruding into the vagina is often found on physical examination.
Retroperitoneal hematomas are asymptomatic initially and extend between the folds of broad ligament. Patients suffering will often present with tachycardia, hypotension or shock due to the significant accumulated of blood in the retroperitoneal space. Unless the hematoma is associated with trauma, patients will not present with pain, only signs will be a palpable abdominal mass or fever.

Treatment of hematoma depends mostly on the size and location:
Non-expanding hematomas which are <3cm in size can be managed conservatively with analgesics and application of ice packs. An expanding hematoma or those greater than 3cm is managed effectively with surgical exploration under anesthesia, were an incision is made to evacuate the hematoma. The surgical site should not be sutured and vagina is often packed for 12-24 hours, an indwelling urinary catheter also may be indicated. In the given case, patient presents with a large haematoma (>3cm) which needs surgical excision and evacuation.

Aspiration of the hematoma is not an appropriate treatment. If surgical intervention is indicated excision and evacuation is the preferred option, followed by vaginal packing for 12-24 hours.

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.

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.

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

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

The vaginal epithelium is made of squamous cells. Hence the most common carcinoma that occurs in the Vagina is squamous cell carcinoma. Diagnosis is made with vaginal biopsy. Usually the pain only presents if the disease extends beyond the vagina involving the perineal nerves.

Mammary duct ectasia occurs when the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

Pregnant women with high-grade squamous intraepithelial lesions (HSIL) on cervical cytology should be evaluated with colposcopy. Principles of management of pregnant women include the following:
– An immediate diagnostic excisional procedure should NOT be performed.
– When colposcopy is performed during pregnancy:
– Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy; however, the endocervical canal may be sampled gently with a cytobrush.
– Cervical biopsy should be performed only if a lesion is present that appears to be high grade or suspicious for cancer.
– If the examination is unsatisfactory, repeating the colposcopy after 6 to 12 weeks should allow visualization of the entire squamocolumnar junction.

There is no indication for inducing abortion or performing a hysterectomy.

A cephalic presentation is the one where head of the foetus enters the pelvic cavity at the time of delivery. The commonest form of cephalic presentation is the vertex presentation in which the occiput of the foetus enters the birth canal.

Urinary incontinence can be divided into two main aetiologies, stress incontinence, or overactive bladder. Conservative management include lifestyle interventions, controlling fluid intake, or bladder exercises. If conservative management is no longer efficient, then medications may be indicated. Oxybutynin is an anticholinergic drug used in the treatment of urinary incontinence. As with other anticholinergic drugs, side effects include dry mouth, dry eyes, blurry vision and constipation. About 1 in 10 patients taking Oxybutynin will experience some of these side effects.

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

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. 

FVS has been reported to complicate maternal chickenpox that occurs as early as 3 weeks and up to 28 weeks of gestation. The risk appears to be lower in the first trimester (0.55 per cent). No case of FVS has been reported when maternal infection has occurred after 28 weeks.

Pre-eclampsia presents with other features in addition to the presence of hypertension, also it’s diagnosis cannot be made considered peripheral edema as the only presenting symptom. Proteinuria occurs more commonly in pre-eclampsia than in gestational hypertension and the latter is mostly asymptomatic.

Hypertensive disorders are found to complicate about 10% of all pregnancies. Common one among them is Gestational hypertension, which is defined as the new onset of hypertension after 20 weeks of gestation without any maternal or fetal features of pre-eclampsia, in this case BP will return to normal within three months of postpartum.

Types of hypertensive disorders during pregnancy:
1. Pregnancy-induced hypertension:
a. Systolic blood pressure (SBP) above 140 mm of Hg and diastolic hypertension above 90 mmHg occurring for the first time after the 20th week of pregnancy, which regresses postpartum.
b. The rise in systolic blood pressure above 25 mm of Hg or diastolic blood pressure above 15 mm of Hg from readings before pregnancy or in the first trimester.
2. Mild pre-eclampsia:
BP up to 170/110 mm of Hg in the absence of associated features.
3. Severe pre-eclampsia:
BP above 170/110 mm of Hg and along with features such as kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise.
4. Essential (coincidental) hypertension:
Chronic underlying hypertension occurring before the onset of pregnancy or persisting after postpartum.
5. Pregnancy-aggravated hypertension:
Underlying hypertension which is worsened by pregnancy.

To diagnose pre-eclampsia clinically, presence of one or more of the following symptoms are required along with a history of onset of hypertension after 20 weeks of gestation.
– Proteinuria: Above 300 mg/24 h or urine protein
reatinine ratio more than 30 mg/mmol.
– Renal insufficiency: serum/plasma creatinine above 0.09 mmol/L or oliguria.
– Liver disease: raised serum transaminases and severe epigastric or right upper quadrant pain.
– Neurological problems: convulsions (eclampsia); hyperreflexia with clonus; severe headaches with hyperreflexia; persistent visual disturbances (scotomata).
– Haematological disturbances like thrombocytopenia; disseminated intravascular coagulation; hemolysis.

An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

The risk of uterine perforation is 0.1% during therapeutic hysteroscopy.

Ergometrine has a half life of 30-120 minutes.

The round ligament is a remnant of the gubernaculum in females. In males it persists as the scrotal ligament.

In early pregnancy Progesterone is produced by the corpus luteum.. This organ is fundamental for pregnancy maintenance until the placenta (syncytiotrophoblast) takes over its function at the 7-9th week of gestation, just after the expression of major histocompatibility complex antigens is suppressed in extra-embryonic fetal tissue.

Gonadotropin-releasing hormone (GnRH) is the hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.

Tamoxifen is a SERM that is effective in treating hormone-responsive breast cancer, it acts as an antagonist to prevent receptor activation by endogenous oestrogen. As agonist of the endometrial receptors it promotes endometrial hyperplasia and hence increases the risk of endometrial cancer.

The following shift the oxygen dissociation curve to the right: Increased temperature Increased H+ (i.e. acidosis) Increased 2,3 DPG Increased pCO2 The following shift the oxygen dissociation curve to the left: Increasing pCO shifts the curve to the left Decreased temperature Decreased [H+] (alkalosis) Decreased 2,3 DPG The Oxygen Dissociation Curve for fetal haemoglobin lies to the left of the normal adult Oxygen Dissociation Curve as it has a higher affinity for Oxygen.

Consuming alcohol and risk of cervical cancer are not associated. Not even drinking often and in large amounts are risk factors for developing cervical cancer.

So drinking alcohol and risk of cervical cancer aren’t associated. Based on their analyses of the scientific research evidence, that is the conclusion of, among many others, the:
American Cancer Society.
Centres for Disease Control and Prevention (CDC).
National Cancer Institute.
UK’s National Health Service.
Canadian Cancer Society.
Cancer Council Australia.
World Health Organization (WHO).

All other options can increase the risk of acquiring cervical cancer.

If a patient presents with PROM at 27 weeks of gestation, her management plan would have to include:

1) Cervical swabs to rule out infection
2) Commencement of prophylactic antibiotics such as erythromycin until results from the swabs are available
-If only normal vaginal flora are seen, prophylactic antibiotics can be stopped.
3) Administration of glucocorticoid- usually for 48 hours to promote maturity of the fetal lung and lower the chance of intracranial bleeding if the foetus has to be delivered prematurely
4) Transfer to a healthcare centre that has neonatal intensive care facilities to ensure if intensive care is needed post-delivery, the healthcare staff are prepared
5) Blood profile (particularly white cell count) and inflammatory markers (CRP) to look for any signs of chorioamnionitis
6) CTG assessment every 2-3 days. Abnormalities found on the CTG tracing are often the first evidence of problems such as a subclinical chorioamnionitis
7) Tocolysis with tocolytics such as IV salbutamol or nifedipine if contractions start before the course of glucocorticoid therapy is finished. Post-glucocorticoid therapy, tocolysis would not be often employed since there is a risk of masking contractions that occur due to an infection. In those cases, it is better to deliver the baby rather than to prolong the pregnancy. If there is no infection, the management plan should aim to prolong the pregnancy and delay delivery of a very premature baby.

This lady should be admitted to hospital for early surgical exploration. Taking into account her age, mild abdominal discomfort and a palpable lower abdominal mass, it is imperative that ovarian malignancy be ruled out as soon as possible. Patients with ovarian malignancy often present in advanced stages of cancer as the symptoms tend to be occult and non-specific. Other things to include in her workup would be her CA125 level. Any form of hormonal therapy is contraindicated until ovarian malignancy has been ruled out. A pap smear is not relevant here since we are suspecting an ovarian malignancy rather than cervical. Evaluation of her mass takes priority over an assessment for osteoporosis.

Mefenamic acids is a NSAID. It works by inhibiting prostaglandin synthesis – It inhibits COX-1 and COX-2 hence reducing the process of inflammation. Activation of antithrombin III and inactivation of factor Xa is the primary mechanism of action of Heparin.

Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.

Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).

Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.

Pregnant women need to get enough folic acid. The vitamin is important to the growth of the foetus’s spinal cord and brain. Folic acid deficiency can cause severe birth defects known as neural tube defects. The Recommended Dietary Allowance (RDA) for folate during pregnancy is 600 micrograms (µg)/day.

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.

HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.

The uterus needs support in order to remain centered inside the pelvic cavity. The support it receives comes in two forms: dynamic and passive. The ligaments of the uterus have an important role in both.

Dynamic support is provided by the pelvic diaphragm through tonic contractions while standing and sitting and active contractions during moments of increased abdominal pressure, such as coughing or sneezing. During these moments, the ligaments of the uterus transmit the force of the diaphragm towards the organ itself, maintaining its position.

The ligaments are also crucial in providing passive support. By minimizing movement of the body and the cervix, they maintain the uterus in the typical anteverted and anteflexed position directly on top of the bladder. This provides a support for the uterus when the abdominal pressure increases.

Hence, even though the broad ligament, round ligament and ovarian ligament have some role in the suspension of the uterus, the uterosacral ligament plays the most significant role. It is also the ligament used for surgical suspension of POP.

Trichomoniasis is considered a sexually transmitted infection found both in men and women caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis for a HIV positive woman who is pregnant is 500mg of metronidazole twice daily for 7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated, and screening for other STIs should be carried out.

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

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.

During early pregnancy, hCG can be detected in the maternal serum as early as 6 to 8 days after fertilization. hCG levels are dynamically increased and doubled every 48 h in most normal pregnancies, and this pattern is similar in both in vivo or in vitro (IVF) conceptions.

A type II deceleration is due to placental insufficiency which can result in fetal distress and asphyxia. The fetal heart rate is lowest at the start of the contraction and returns to normal after the contraction is complete.

In post menopausal women the thickness of the endometrium should be 4mm or less or women on tamoxifen is should be less than 5mm. If it is more than this the patient should be worked up for endometrial carcinoma.

Preterm birth is the leading cause of neonatal morbidity and mortality not attributable to congenital anomalies or aneuploidy. It has been shown that a shortened cervix is a powerful indicator of preterm births in women with singleton and twin gestations – the shorter the cervical length, the higher the risk of spontaneous preterm birth. Ultrasound measurements of the cervix are a more accurate way of determining cervical length (CL) than using a digital method.

25 mm has been chosen as the ‘cut off’ at above which a cervix can be regarded as normal, and below which can be called short. A cervix that is less than 25 mm may be indicative of preterm birth.

The broad ligament is one of the secondary supporting structures of the uterus which attaches the lateral portion of the uterus to the pelvic sidewall. The broad ligament primarily serves a protective layer for important structures including the fallopian tubes, the ovaries, the ovarian arteries, and the uterine arteries, the round and ovarian ligaments, and the infundibulopelvic ligaments.

Glucagon release is inhibited by increased blood glucose, ketones, free fatty
acids, insulin, raised urea levels and somatostatin. Glucagon is produced by alpha cells of the pancreas and increases the plasma glucose level by stimulating glycogenolysis and gluconeogenesis.

The patient is suffering from Bartholin cyst abscess.
Insertion of an inflatable balloon is a non-surgical procedure that can be performed as an outpatient using a local anaesthetic (LA) injection to numb the area. It involves making a passage from the cyst or abscess through which the pus can drain over 4 weeks. After the LA injection, a small skin cut is made into the cyst or abscess, which allows drainage. A fluid/ pus swab sample may be taken to check for an infection at this stage. A cotton bud is used to break the pockets of abscess/ cyst fluid. A flexible tube (called a Word catheter) with a small, specially designed balloon at its tip is then inserted into the cyst or abscess to create a passage. The balloon is inflated with 3–4mls of sterile fluid to keep the catheter in place. Rarely, a stitch may be used to partly close the cut and hold the balloon in position. It is then left in place for up to 4 weeks; new skin to forms around the passage and the wound heals.

Marsupialization can be done for drainage but is inferior or word catheter because of the technical challenges and complications. Hot compressions and analgesics alone do not suffice in the presence of an abscess. Antibiotics are given after drainage but are not effective alone when there is a large collection of pus.

The use of long-acting reversible contraceptives (LARCs) is globally accepted as a strategy that is successful in decreasing rates of unintended pregnancy, especially in very young women.
Long-acting reversible contraceptives (LARCs) are defined as any contraceptive that requires administration less than once per cycle (i.e. per month). This includes copper and progestogen-only intrauterine devices (IUDs), and progestogen subdermal implants and injections. However, subdermal implants and IUDs, which have a life of at least three years, have superior efficacy over injections, which require administration every three months. Implants and IUDs are highly cost-effective when compared with other contraceptive methods.

LARCs are widely recommended by professional bodies and the World Health Organization (WHO) as first-line contraception for young women as they are safe, effective and reversible. Young women should be offered the choice of a LARC as part of a fully informed decision for their first form of contraception.

LARCs surpass barrier methods and contraceptive pills in effectiveness and safety therefore all other options are incorrect.

The venous drainage of the uterus is via the uterine veins which form a plexus passing below the artery within the base of the broad ligament communicating with the rectal and the vesical venous plexus before draining into the internal iliac veins.

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

Premenopausal women with asymptomatic simple cysts smaller than 8cm on sonograms in whom the CA125 value is within the reference range may be monitored, with a repeat ultrasonographic examination in 8-12 weeks.

Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts should be considered for surgical removal.

For this patient, a premenopausal woman, with an ovarian cyst size 8 cm x 12cm. Surgical management is indicated, hence referral to gynaecologist is appropriate.

Laparotomy or laparoscopic excision of cyst should be considered and performed by the gynaecologist not general practitioner.

Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

Alcohol exposure during pregnancy results in impaired growth, stillbirth, and fetal alcohol spectrum disorder. Fetal alcohol deficits are lifelong issues with no current treatment or established diagnostic or therapeutic tools to prevent and/or ameliorate some of these adverse outcomes.

Alcohol readily crosses the placenta with fetal blood alcohol levels approaching maternal levels within 2 hours of maternal intake. As there is known safe level of alcohol consumption during pregnancy, and alcohol is a known teratogen that can impact fetal growth and development during all stages of pregnancy, the current recommendation from the American College of Obstetricians and Gynaecologists, Centre for Disease Control (CDC), Surgeon General, and medical societies from other countries including the Society of Obstetricians and Gynaecologists of Canada all recommend complete abstinence during pregnancy.

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

Despite the fact that pregnancy at her age is uncommon, the best advise you can give her is to take a pregnancy test.

If the test results show she is not pregnant, she can next decide whether to restart the oral contraceptive pill (0CP) or simply weep until the post-pill amenorrhoea goes away.

Although an increased follicle-stimulating hormone (FSH) level may indicate ovarian failure, it does not guarantee that no more periods will occur and does not rule out the possibility of a future pregnancy.

Obviously, she should be recommended to use a contraceptive method like condoms until the cause of her amenorrhoea is determined.
Other hormonal tests, such as luteinizing hormone and prolactin testing, may be required.

This is Polymorphic Eruption of Pregnancy (PEP) also known as Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP). Papules and plaques form on the abdomen (commonly within striae). It is most common in women during their first pregnancy and typically occurs in the 3rd trimester.

The most common hereditary cancer in the breast ovarian cancer syndrome accounts for 90% of the hereditary cancers. It is due to mutations in the BRCA 1 and BRCA 2 genes, most commonly the BRCA 1 gene accounting for 70% life time risk of breast cancer and 40% life time risk of ovarian cancer.