The treatment of asphyxia starts with the correct perinatal management of high-risk pregnancies. The management of the hypoxic-ischemic new-borns in the delivery room is the second fundamental step of the treatment. Low Apgar scores and need for cardiopulmonary resuscitation at birth are common but nonspecific findings. Most new-borns respond rapidly to resuscitation and make a full recovery. The outcomes for new-borns who do not respond to resuscitation by 10 minutes of age are very poor, with a very low probability of surviving without severe disability. Resuscitation in room air is advised for term new-borns, since the use of 100% oxygen is associated with worse outcomes compared to the use of room air.

Spontaneous abortion is the loss of pregnancy naturally before twenty weeks of gestation. Colloquially, spontaneous abortion is referred to as a ‘miscarriage’ to avoid association with induced abortion. Early pregnancy loss refers only to spontaneous abortion in the first trimester. In 50% of cases, early pregnancy loss is believed to be due to fetal chromosomal abnormalities. Advanced maternal age and previous early pregnancy loss are the most common risk factors. For example, the incidence of early pregnancy loss in women 20-30 years of age is only 9 to 17%, while the incidence at 45 years of maternal age is 80%. Other risk factors include alcohol consumption, smoking, and cocaine use.

Several chronic diseases can precipitate spontaneous abortion, including diabetes, celiac disease, and autoimmune conditions, particularly anti-phospholipid antibody syndrome. Rapid conception after delivery and infections, such as cervicitis, vaginitis, HIV infection, syphilis, and malaria, are also common risk factors. Another important risk factor is exposure to environmental contaminants, including arsenic, lead, and organic solvents. Finally, structural uterine abnormalities, such as congenital anomalies, leiomyoma, and intrauterine adhesions, have been shown to increase the risk of spontaneous abortion.

Atenolol is considered teratogenic and has two main risks: fetal bradycardia and neonatal apnoea. ACE inhibitors and angiotensin II receptor blockers are also known to be teratogenic (even though large-scale studies are difficult to conduct during pregnancies).

Non-severe Hypertension and asymptomatic at ≥ 20w
(BP ≥ 140/90 and < 160/110mmHg)
• Urine dipstick analysis
• Quantify 24hr urine protein excretion/U-PCR
• Start Methyldopa 500mg 8hrly
• Do Hb, Platelet count, s-Cr, AST/ALT, Urine specimen for MC&S
• If gestational hypertension is diagnosed and BP is well controlled, continue antihypertensive therapy and plan delivery at 38 weeks if all remains well in the interim

Hypertension with symptoms or severe features
• Admit in High care unit and nurse in left lateral
• Insert urinary catheter and IV line
• Administer IV Ringers lactate (total volume of IV fluid administered should not exceed
80mls/hr)
• Start Magnesium Sulphate
• Control BP
• Perform an ultrasound (if indicated) or assess clinically to determine fetal viability,
EFW (Estimated Fetal Weight) and liquor volume and, if possible
• If GA ≥ 34/40 or EFW ≥ 2200g expedite delivery
• If GA ≥ 26/40 and < 34/40, administer course of steroids to enhance fetal lung maturity
• If patient is stabilised, offer expectant management if < 34 weeks and eligible

Acute severe hypertension (DBP ≥ 110mmHg and or SBP ≥ 160mmHg)
• Administer Nifedipine (Adalat®) 10mg per os immediately
• Start maintenance therapy with Nifedipine (Adalat XL®) 30-60mg BD orally (maximum
120mg/day)
• Aim for DBP ≤ 110 and SBP ≤ 160mmHg
• If BP is still high after 30 minutes, repeat Nifedipine (Adalat®) 10mg orally every 30
minutes, for a maximum of three dosages or until BP < 160/110mmHg (contraindication:
tachycardia > 120 bpm, unable to swallow, cardiac lesion).
• If after 30 minutes BP is still high then give Labetalol 20, 40, 80, 80 and
80mg (max 300mg) as bolus doses at 10 minute intervals, checking BP every 10
minutes until BP < 160/110mmHg. Contra-indications: patients with asthma and
ischaemic heart disease. If BP monitoring is not achievable at 10 minute intervals then
patient should be transferred to ICU for a Labetalol infusion.

To help protect babies during this time when they are most vulnerable, women should get the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.

Pregnant women should receive Tdap anytime during pregnancy if it is indicated for wound care or during a community pertussis outbreak.
If Tdap is administered earlier in pregnancy, it should not be repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.

Optimal timing is between 27 and 36 weeks gestation (preferably during the earlier part of this period) to maximize the maternal antibody response and passive antibody transfer to the infant.
Fewer babies will be hospitalized for and die from pertussis when Tdap is given during pregnancy rather than during the postpartum period.

This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

Caesarean section is rarely needed to be done when the foetus is already dead.

Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

Visual disturbances although very common during pregnancy are not a normal sign. Physicians should have a firm understanding of the various ocular conditions that might appear pregnancy or get modified by pregnancy. In addition, it is very important to be vigilant about the rare and serious conditions that may occur in pregnant women with visual complaints. Prompt evaluation may be required and the immediate transfer of care of the patient may help saving the lives of both the mother and the baby.

Elements of the Apgar score include colour, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression or apnoea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score 7 or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.

Multiple pregnancy is considered a high risk for obstetric complications such as spontaneous abortion, hypertensive disorders, placenta previa, and fetal malformations. Specifically, the incidence of hypertensive disorders, a common source of maternal morbidity, is 15% to 35% in twin pregnancies, which is two to five times higher than in singleton pregnancies. Additionally, the aetiology of preterm birth is not completely understood, but the association between multiple pregnancy and preterm birth is well known. A secondary analysis of the WHO Global Survey dataset indicated that 35.2% of multiple births were preterm (< 37 weeks gestation); of all multiple births, 6.1% of births were before 32 weeks gestation, 5.8% were during weeks 32 and 33, and 23.2% were during weeks 34 through 37

In patients who have an HbA1C value above 10%, it is better to postpone pregnancy until diabetes is under control. Also in those patients with type 2 diabetes mellitus, who are suffering from severe gastroparesis, those with advanced retinopathy, with severe diabetic renal disease and severe ischemic heart disease with uncontrolled hypertension pregnancy is contraindicated.

All the other options mentioned are incorrect.

Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.

Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.

Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.

Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.

Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.

In this pregnant patient with an antepartum haemorrhage at 37 weeks of gestation, her clinical presentation points to a placenta previa. Her bleeding has stopped, the uterus is of the expected size and non-tender, and the fetal head is still mobile above the pelvic brim which are all findings that would be consistent with a placenta praevia. An ultrasound examination would be done to rule-out or diagnose the condition.

An Apt test on the blood is necessary to ensure that this is not fetal blood that would come from a ruptured vasa praevia. Although this diagnosis would be unlikely since the bleeding has stopped. If there was a vasa praevia, there would be fetal tachycardia or bradycardia, where a tachycardia is often seen first but then bradycardia takes over late as fetal exsanguination occurs.

In a placental abruption with concealment of blood loss, the uterus would be larger and some uterine tenderness would be found on exam.

A cervical polyp could bleed after sexual intercourse and a speculum examination would be done to exclude it. However, it would be unlikely for a cervical polyp to cause such a large amount of blood loss. A heavy show would also rarely have as heavy as a loss of 200mL.

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).

Women who are at high risk of having babies with neural tube defects and who would benefit from higher doses of folic acid include those with certain folate-enzyme genotypes, previous pregnancies with neural tube defects, diabetes, malabsorption disorders, or obesity, or those who take antifolate medications or smoke. Such women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

Vascular spiders or angiomas, are of no clinical significance during pregnancy as these are common findings and are form as a result of hyperestrogenemia associated with normal pregnancies. These angiomas, as they will resolve spontaneously after delivery, does not require any additional workup or treatment.
Reassurance to the patient is all that is required in this case.

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.

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 principal screening test for detecting maternal HBV infection is the serologic identification of HBsAg. Screening should be performed in each pregnancy, regardless of previous HBV vaccination or previous negative HBsAg test results.

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (e.g., injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Interventions to prevent perinatal transmission of HBV infection include screening all pregnant women for HBV, vaccinating infants born to HBV-negative mothers within 24 hours of birth, and completing the HBV vaccination series in infants by age 18 months.

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

Common risk factors for Rectovaginal fistula are Pelvic radiation, Obstetric trauma, Pelvic surgery, Colon cancer, Diverticulitis and Crohn disease. Uncontrollable passage of gas &/or feces from the vagina is considered the common clinical feature of Rectovaginal fistula.
Diagnosis is done with the help of physical examination, fistulography, Magnetic resonance imaging and Endosonography.

This patient, mentioned in the case, presents with malodorous vaginal discharge (ie, stool), gas passing through the vagina, and a posterior vaginal lesion most likely has a rectovaginal fistula, which is an aberrant connection between bowel and vagina.  Although development of rectovaginal fistula is commonly associated with obstetric trauma or pelvic surgery, patients without these risk factors are recommended to be evaluated for other additional causes like gastrointestinal conditions.
This patient’s intermittent, crampy abdominal pain and perianal sinus in the setting of a rectovaginal fistula is most likely due to an underlying Crohn disease.  Crohn disease, is a transmural inflammation of the gastrointestinal tract, which predisposes patients to bowel abscess, fissure, and fistula formation.  Although the rectum is typically spared in Crohn disease, a non-healing, transmural ulcer present in the anal canal can progress to form a rectovaginal fistula.
In addition to standard Crohn disease management like anti-TNF inhibitors, glucocorticoids, etc patients with a rectovaginal fistula may require surgical correction.

Bartholin gland cysts or abscesses can present with malodorous vaginal discharge; however, patients typically have a posterior vulvar mass located at the 4 or 8 o’clock position. In addition, Bartholin gland cysts will not present with crampy abdominal pain or passage of flatus or stool through the vagina.

Hidradenitis which is the chronic occlusion and inflammation of hair follicles, can cause groin abscesses with sinus tracts and associated purulent drainage.  However, it is not associated with abdominal pain or malodorous vaginal discharge. In addition, this condition is typically multifocal and located in more than one intertriginous areas like axillary, inguinal or gluteal regions.

Cervical cancer or a retained foreign body in the vagina can cause malodorous vaginal discharge and abdominal pain.  However, patients will typically have visible findings like cervical lesion, foreign body etc on speculum examination, and these neither are associated with the passage of flatus through the vagina.

Complications of Crohn disease include perianal disease like abscess, fissure and fistula like rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract.  Patients with a rectovaginal fistula typically presents with malodorous, tan vaginal discharge, passage of flatus through the vagina and a posterior vaginal lesion.

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.

The case is most likely diagnosed a threatened miscarriage.
A diagnosis of threatened miscarriage is made when there is uterine bleeding in the presence of a closed cervix and is confirmed by the sonographic visualisation of an intrauterine pregnancy with detectable fetal cardiac activity. Miscarriages may not always follow even though there was multiple episodes or large amounts of bleeding, therefore the term “threatened” is used in these cases.
At 7 to 11 weeks of gestation, about 90 to 96 percent cases of pregnancies, will not usually miscarry if they have presented with an intact fetal cardiac activity along with vaginal bleeding and if bleeding occurs at the later weeks of gestational age chances of success rate is higher.

Topic review:
– Inevitable miscarriages presents with a dilated cervix, increasing uterine bleeding and painful uterine contractions. The gestational tissues can often be felt or seen through the cervical os and its passage occurs within a short time.
– In Incomplete miscarriage, the membranes will rupture passing the fetus out, but significant amounts of placental tissue will be retained. This occurs most commonly in late first trimester or early second trimester. On examination, the cervical os will be opened and the gestational tissue can be observed in the cervix, with a uterine size smaller than expected for gestational age, but not well contracted. The amount of bleeding varies but can be severe enough to cause hypovolemic shock. There will be painful cramps
ontractions and ultrasound reveals tissue in the uterus.
– A missed miscarriage refers to the in-utero death of the embryo or fetus prior to 20th week of gestation, with retention of the pregnancy for a prolonged period of time. In this case, women may notice that symptoms associated with early pregnancy like nausea, breast tenderness, etc have abated and they don’t “feel pregnant” anymore.
Vaginal bleeding may occur but the cervix usually remains closed. Ultrasound reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.
– Complete miscarriage, usually occurs before 12 weeks of gestation and the entire contents of the uterus will be expelled resulting in a complete miscarriage. In this case, physical examination reveals a small, well contracted uterus with an open or closed cervix with scanty vaginal bleeding and mild cramping. Ultrasound will reveal an empty uterus with no extra-uterine gestation.

If a pregnant woman develops primary herpes simplex infection after 30 weeks gestation, her risk for transmission of herpes simplex virus to the neonate leading to neonatal infection increases significantly.
Below mentioned are the most common risk factors resulting in intrapartum herpes simplex infection of the baby:
– Premature labor
– Premature rupture of membrane
-Primary herpes simplex infection near the time of delivery
– Multiple lesions in the genital area
The most appropriate management for such case includes:
– Checking for herpes simplex infection with PCR testing (cervical swab)
– Prophylactic antiviral therapy of the mother from 36th week until delivery
– Cesarean section delivery

In the case above mentioned, it is better to start antiviral therapy immediately and consider cesarean section to minimize the risk of vertical transmission of infection to the neonate.

Pituitary tumours, the most common pathologic cause of galactorrhoea can result in hyperprolactinemia by producing prolactin or blocking the passage of dopamine from the hypothalamus to the pituitary gland. Approximately 30 percent of patients with chronic renal failure have elevated prolactin levels, possibly because of decreased renal clearance of prolactin. Primary hypothyroidism is a rare cause of galactorrhoea in children and adults. In patients with primary hypothyroidism, there is increased production of thyrotropin-releasing hormone, which may stimulate prolactin release. Nonpituitary malignancies, such as bronchogenic carcinoma, renal adenocarcinoma and Hodgkin’s and T-cell lymphomas, may also release prolactin.

Oesophageal atresia of the foetus interrupts the normal circulation of the amniotic fluid. This causes polyhydramnios and subsequent distension of the uterus impacting proper expansion of the lungs. This would explain the difficulty breathing.

There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria

The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.

Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.

Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.

At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.

Twin gestations are generally at increased risk of complications and this risk is further stratified based on the chorionicity ie. number of placentas and amnionicity, the number of amniotic sacs of the gestation. In the given case patient has monochorionic diamniotic twins, which means 1 placenta and 2 amniotic sacs, based on the presence of 2 embryos, a single placenta and a thin intertwin membrane composed of 2 amniotic sacs that meets the placenta at a 90-degree angle (“T sign”). In patients who appear to have a single placenta, the base shape of the intertwin membrane distinguishes between a monochorionic (“T sign”) and fused dichorionic (“lambda sign”) gestation.
Monochorionic twins are at high risk for twin-twin transfusion syndrome (TTTS), which is a complication that can result in heart failure and fetal
eonatal mortality in both twins. In TTTS, unbalanced arteriovenous anastomoses are present between the shared placental vessels that supply the twins, because of these anastomoses, blood from the placental arteries from one twin (donor), which is of high resistance/pressure, is shunted into the placental veins of the other twin (recipient) with low resistance/pressure. This shunting of blood away from the donor twin causes anemia that leads to renal failure, oligohydramnios, low-output heart failure, and fetal growth restriction. In contrast, the shunting of blood toward the recipient twin causes polycythemia, which leads to polyhydramnios, cardiomegaly, high-output heart failure and hydrops fetalis. This in turn makes both twins at high risk for intrauterine and neonatal death.
Mild TTTS is expectantly managed with serial ultrasounds to evaluate for worsening clinical features, whereas moderate-to-severe cases are treated with laser coagulation of the placental anastomoses.

In monozygotic twins, placentation type is determined by timing of the twinning.  Twinning that occurs shortly after fertilization yields a dichorionic diamniotic gestation.  In contrast, the incomplete division (ie, fission) that can lead to conjoined twins occurs later in development and yields a monochorionic monoamniotic gestation. As the twins are in the same sac, monochorionic monoamniotic gestations can be complicated by cord entanglement but not possible in the given case as this patient has diamniotic twins.

Risk factors for placenta accreta, implantation of the placenta directly into the myometrium, include placenta previa and prior uterine surgeries like cesarean delivery, myomectomy, etc

Twin pregnancies are at increased risk of placenta previa (placental tissue that covers the internal cervical os); however, this patient has a fundal placenta, making this complication unlikely.

Monochorionic twin gestations can be complicated by twin-twin transfusion syndrome, which is potentially a fatal condition that results from unbalanced vascular anastomoses between the vessels supplying umbilical cords of each twin.

The effects of smoking on the outcomes of pregnancy are well documented and include an increased risk of preterm premature rupture of the membranes (PPROM), preterm birth, low birth weight, placenta previa, and placental abruption. Many studies have shown that the risk of Sudden Infant Death Syndrome (SIDS) is increased by maternal smoking during pregnancy.

A serious complication with a miscarriage is DIC, a severe blood clotting condition and is more likely if there is a long time until the foetus and other tissues are passed, which is often the case in missed abortion.

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.

Uncontrolled endometrial proliferation due to excess and unregulated estrogen is the reason for intermenstrual bleeding and irregular menses along with abnormal uterine bleeding (AUB) in this patient. The condition is mostly associated with an increased risk of endometrial hyperplasia
ancer.
The absolute risk of endometrial hyperplasia
ancer is very low in women aged <45, therefore they can be started on combination medication with estrogen/progestin contraception (ie, medical management) without the evaluation of endometrium.  The estrogen component of medication regulates the menstrual cycle by build up the endometrium; whereas the progestin component helps in shedding of the endometrium.
However, patients who have continued irregular menstrual bleeding even while on combination contraceptives require further evaluation as they have failed to improve with medical management. In such patients, the endometrial lining will be too thick for the progestin to completely shed during menstruation and this unshed endometrium continues to undergo dysregulated proliferation, leading to an increased risk of endometrial hyperplasia
ancer. Therefore, patients age below 45 with AUB who have failed medical management require an endometrial biopsy.
AUB persistent above 6 months, obesity, and/or tamoxifen therapy are the other indications for endometrial biopsy in women age <45, as all of these will increase the amount of unopposed endometrial estrogen exposure. In patients with heavy menstrual bleeding and anemia, coagulation studies are performed to evaluate for bleeding disorders like von Willebrand disease. It is not necessary in this patient as she have a normal hemoglobin level. In patients with heavy, but regular (ovulatory) bleeding an endometrial ablation, which is a procedure used to remove the excess endometrium, can be considered as the treatment option. Endometrial ablation is contraindicated in undiagnosed cases of AUB as it prevents evaluation of the endometrium in patients with possible endometrial hyperplasia
ancer.

To check for abnormalities of the uterus like didelphys or of the Fallopian tube like scarring, a hysterosalpingogram is used but it is not useful to evaluate AUB. In addition, as the procedure could spread cancerous endometrial cells into the abdominal cavity, hysterosalpingogram is contraindicated in cases of undiagnosed AUB.

To evaluate secondary amenorrhea, ie. absence of menses for >6 months in a patient with previously irregular menses, a progesterone withdrawal test is used to determine whether amenorrhea is from low estrogen level, in negative cases there will be no bleeding after progesterone. This test is not indicated or relevant in this case as patient had continued bleeding while on oral contraceptives suggestive of high estrogen levels.

Evaluation for endometrial hyperplasia
ancer with an endometrial biopsy is required for those women age <45 with abnormal uterine bleeding who have failed medical management with oral contraceptives.

Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.