The pudendal nerve is formed by sacral nerve roots S2, S3 and S4 almost immediately as they exit the spinal foramina. The pudendal nerve exits the pelvis via the greater sciatic foramen, travels behind the sacrospinous ligament before re-entering the pelvis via the lesser sciatic foramen. It is an important nerve to be aware of as it supplies sensation to the genitalia and can also be damaged/compressed at a number of places along its course. Image sourced from Wikipedia

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

The presentation is antepartum haemorrhage. Ultrasound should be performed to find the reason for bleeding and assess the fetal well being.

The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labour soon. They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.

Hormones that increase during pregnancy and their roles:

1. Human Chorionic Gonadotropin (hCG): Peaks between the eighth to tenth weeks of gestation and supports the corpus luteum to maintain progesterone production.
2. Progesterone: Initially produced by the corpus luteum and later by the placenta, it rises steadily throughout pregnancy, suppressing the maternal immune response to fetal antigens and preparing the endometrium for implantation.
3. Estrogen: Produced by the placenta from fetal and maternal precursors, estrogen levels increase to promote uterine growth and blood flow.
4. Human Placental Lactogen (hPL): Rises significantly during pregnancy, influencing maternal metabolism by increasing insulin resistance and promoting lipolysis.
5. Relaxin: Increases early in pregnancy to relax the uterine muscles, inhibit contractions, and prepare the cervix and pelvis for childbirth.
6. Prolactin: Levels increase to prepare the breasts for lactation.
7. Corticotropin-Releasing Hormone (CRH): Increases towards the end of pregnancy and is involved in the timing of labor.
8. Adrenocorticotropic Hormone (ACTH): Levels increase, contributing to elevated cortisol levels during pregnancy.
9. Total Thyroxine (T4): Levels increase due to elevated thyroid-binding globulin (TBG) production stimulated by increased estrogen levels, meeting the increased metabolic demands of pregnancy.
10. Parathyroid Hormone (PTH): Levels increase to regulate calcium metabolism, ensuring adequate calcium for fetal bone development.
11. Cortisol: Levels increase due to higher production by the adrenal glands and increased binding to cortisol-binding globulin (CBG), supporting glucose metabolism, managing stress, and aiding fetal development, particularly lung maturation.

During pregnancy, some hormones either remain stable or do not increase significantly. These include:

1. Follicle-Stimulating Hormone (FSH): Levels decrease due to the negative feedback from high levels of estrogen and progesterone.
2. Luteinizing Hormone (LH): Levels also decrease due to negative feedback from elevated estrogen and progesterone.
3. Growth Hormone (GH): Although a variant of growth hormone (hGH-V) is produced by the placenta and increases, the maternal pituitary GH levels may not significantly increase.
4. Melatonin: Generally remains stable during pregnancy, though some studies suggest there may be slight fluctuations.
5. Insulin: While insulin resistance increases due to hPL and other factors, the actual levels of insulin may not increase proportionally; instead, pancreatic beta-cell function adapts to meet the increased demand.

The most common clinical findings in a postpartum women with endometritis are postpartum fever, with tachycardia relative to the rise in temperature, midline lower abdominal pain and uterine tenderness from the 2nd to 10th day of postpartum.

Most common risk factors for the development of postpartum endometritis are:
– Cesarean deliveries are considered as the most important risk factor for postpartum endometritis, especially those performed after the onset of labour.
– Young maternal age.
– Multiple digital cervical examinations.
– Prolonged rupture of membranes.
– Retention of placental products.
– Prolonged labour.
– Chorioamnionitis.
Advanced maternal age is not considered as a risk factor for development of postpartum endometritis.

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.

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.

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

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.

Normal menstrual blood loss is about 40-45 ml. More than 80 ml per period is defined as heavy menstrual bleeding.

Premature menopause occurs if menopause happens before the age of 40. It effects 1% of women under the age of 40 and 0.1% under 30.

Fat necrosis may occur following a traumatic injury to the breast. The lump is usually firm, round, and painless.

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.

Oxytocin stimulates the myoepithelial cells in the breast causing the milk production. It also helps augment contractions in labour and cause uterine involution after childbirth.

If diarrhoea occurs within 24 hours of taking oral birth control or continues for 24 to 48 hours after taking a pill, an additional dose is not needed.

If diarrhoea lasts more than 48 hours the patient should use backup birth control, such as condoms, or avoid sexual intercourse until pills have been taken for seven diarrhoea-free days.

Options to stop pills are incorrect as it increases risk of pregnancy.

The median umbilical ligament is the remnant of the Urachus.

A rare complication of pelvic inflammatory disease is Fitz Hugh Curtis syndrome which is perihepatitis leading to the formation of adhesions between the liver and the peritoneal surface. It is most commonly caused by chlamydia and gonorrhoea. Ophthalmia neonatorum is conjunctivitis which is also caused by these pathogens.

TORCH infections are responsible for perinatal complications. CMV is the most common amongst them. Primary infection often produces no symptoms or mild non-specific flu-like symptoms in the mother. The diagnosis is often made after abnormalities are seen in the foetus on ultrasound scan. The main features seen in an affected foetus are FGR, microcephaly, ventriculomegaly, ascites or hydrops. Some foetuses which are infected may not show any features on ultrasound, but may later be found to have neurological damage such as blindness, deafness or developmental delay. The neonate can also be anaemic and thrombocytopenic, with hepatosplenomegaly, jaundice and a purpureal rash.

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.

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. In babies born with congenital CMV about 10-15% are symptomatic, while 10-15% of those who are asymptomatic will develop symptoms 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.

Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.

A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).

Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.

PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.

Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.

Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.

Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).

In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.

The average menstrual blood loss is 35-40ml The maximum normal blood loss is 80ml

Features of functional ovarian cysts on ultrasound are: Thin walled and unilocular Must be >3cm diameter (if <3cm described as follicle) Anechoic (absence of internal echoes) No colour flow No solid components

This patient has developed symptoms of ovulation discomfort, which is also known as Mittelschmerz syndrome. Lower abdominal and pelvic pain that arises around the middle of a woman’s menstrual cycle characterises this condition.
The discomfort usually appears suddenly and disappears within hours, though it can continue up to three days.

The symptoms of ovulation pain can include:
– Lower abdomen pain.
– The pain typically occurs about two weeks before the menstrual period is due.
– The pain is felt on the right or left side, depending on which ovary is releasing an egg.
– The pain may switch from one side to the other from one cycle to the next, or remain on one side for a few cycles.
The duration of pain ranges anywhere from minutes to 48 hours.

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%.

Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.

The nuchal lucency measurement is the measure of the nuchal pad thickness. Children with down syndrome have an increased thickness of the nuchal pad. The risk of down’s syndrome increases with maternal age. The nuchal lucency test has an accuracy rate of 70%.

Klinefelter syndrome occurs in 1:1000 individuals. They are phenotypically male and genotypically they have 47,XXY chromosomes. These individuals have small testes, are tall with disproportionate long lower limbs.40% will also have gynecomastia.

Tocolysis is an obstetrical procedure to prolong gestation in patients, some of which are experiencing preterm labour. This is achieved through various medications that work to inhibit contractions of uterine smooth muscle.

There is no definitive first-line tocolytic agent by the American College of Obstetrics and Gynecology (ACOG) but nifedipine is most commonly used. However, in severe aortic stenosis, nifedipine can cause ventricular collapse and dysfunction.

The therapeutic target in the treatment of preterm labour is currently the pharmacological inhibition of uterine contractions with the use of various tocolytic agents. Tocolytic agents are used to maintain pregnancy for 24–48 hours to allow corticosteroids administration to act and to permit the transfer of the mother to a centre with a neonatal intensive care unit.

Oxytocin inhibitors work by competitively acting at the oxytocin receptor site. Oxytocin acts to increase the intracellular levels of inositol triphosphate. The medications currently in this class are atosiban and retosiban. Maternal nor fetal side effects have not been described for this tocolytic.