The perineal membrane (also known as the inferior fascia of the urogenital diaphragm) separates the deep and superficial perineal pouches i.e. it is the inferior border of the deep pouch and superior border of the superficial pouch. The deep perineal pouch is the space therefore between superior and inferior layers of the urogenital diaphragm The superior fascia of the urogenital diaphragm is the superior border

The blastocyst hatchs from the Zona Pellucida

The femoral triangle is bounded:
– Superiorly by the inguinal ligament that forms the base of the femoral triangle.
– Medially by the lateral border of the adductor longus.
– Laterally by the sartorius; the apex of the femoral triangle is formed where the borders of the sartorius and the adductor muscles meet.
– The floor of the femoral triangle is formed by the iliopsoas laterally and the pectineus muscle medially.
– The roof of the femoral triangle is formed by the fascia lata and cribriform
fascia, subcutaneous tissue, and skin.

The incubation period of varicella is 10-21 days.

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.

Thyroxine requirement during pregnancy will increases by 25 to 30 percent, which is seen as early as fifth week of pregnancy.

Children born to those women whose hypothyroidism was inadequately treated during pregnancy, are at higher risk for developing neuropsychiatric impairments.

When a woman who is on thyroxine is planning to conceive, they are advised to increase their thyroxine dose by 30 percent at the time of confirmation of pregnancy.

During pregnancy TSH also should be monitored at every 8 to 10 weeks, with necessary dose adjustments.

Dose requirements of thyroxine will return to pre-pregnancy level soon after delivery and it will not change according to whether the mother is breastfeeding or not.

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

Chickenpox or varicella is a contagious disease caused by the varicella-zoster virus (VZV). The virus is responsible for chickenpox (usually primary infection in non-immune hosts) and herpes zoster or shingles (following reactivation of latent infection). Chickenpox results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the chest, back, and face then spreads. It is accompanied by fever, fatigue, pharyngitis, and headaches which usually last five to seven days. Complications include pneumonia, brain inflammation, and bacterial skin infections. The disease is more severe in adults than in children.

Primary varicella infection during pregnancy can also affect the foetus, who may present later with chickenpox. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the foetus. Varicella infection in pregnant women could spread via the placenta and infect the foetus. If infection occurs during the first 28 weeks of pregnancy, congenital varicella syndrome may develop. Effects on the foetus can include underdeveloped toes and fingers, structural eye damage, neurological disorder, and anal and bladder malformation.

Prenatal diagnosis of fetal varicella can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised.

Antivirals are typically indicated in adults, including pregnant women because this group is more prone to complications.

The treatment of Chlamydia includes avoidance of intercourse, use of condoms and antibiotic treatment. Erythromycin 500mg orally QID for 7 days or Amoxicillin 500mg TDS for 7 days or Ofloxacin 200mg orally BD for 7 days.

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

Gestational Diabetes occurs in 2-9% of all the pregnancies.

Prolactin is the hormone that is responsible for the production of milk (Lactogenesis). Oxytocin is responsible for the let down reflex during suckling.

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

A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK.

A missed miscarriage is described as a loss of pregnancy without vaginal bleeding, loss of tissue, cervical changes or abdominal pain. During a scan, a fetal heartbeat is not observed, and the gestational sac may be small.

A threatened miscarriage is when the cervix dilates and uterine bleeding is seen; the pregnancy could still be viable. A complete miscarriage occurs when all the products of conception are expelled from the uterus, bleeding has stopped, and the cervix has closed up after dilation.

An inevitable miscarriage occurs with the usual symptoms of a miscarriage and a dilated cervix, suggesting that the passage of the fetal tissue is inevitable.

Recurrent miscarriages are described as spontaneous pregnancy loss of more than 2 to 3 consecutive times.

Adolescents who fail to respond to first- or second-line treatment and have recurrent symptoms or have symptoms that worsen over time should be re-evaluated for other possible and serious causes of secondary dysmenorrhea such as endometriosis, uterine leiomyomas, polyps, or pelvic pathologies.

When pelvic pathology is suspected, abdominal and transvaginal ultrasonography should be used as first-line investigation. However, transvaginal ultrasound is more accurate and the preferred option if possible.

CT scan is not indicated in the assessment of dysmenorrhea.

D&C and laparoscopy can be considered as treatment options once a diagnosis has been established but can not be used as primary steps in diagnosis of dysmenorrhea.

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.

Sertoli-Leydig cell tumours constitute less than 0.5 percent of ovarian neoplasms. They may behave in a benign or malignant fashion, which correlates with the degree of differentiation in an individual case. Approximately 75 percent occur in women under the age of 40 years (mean age at diagnosis is 25), but they occur in all age groups. The neoplasms are characterized by the presence of testicular structures that produce androgens. This can result in virilization, although not all of these neoplasms are functionally active.

Pure Sertoli cell tumours are usually estrogenic and may also secrete renin, leading to refractory hypertension and hypokalaemia. In addition, these tumours may be associated with Peutz-Jeghers syndrome.

Pure Leydig cell tumours are androgen secreting; only a few cases have been reported. Virtually all of these rare tumours are unilateral and confined to the ovary at diagnosis.

Granulosa cell tumours typically present as large masses; the mean diameter is 12 cm. Women may present with an asymptomatic mass noted on abdominal or pelvic examination. Granulosa cell tumours often produce oestrogen and/or progesterone; consequently, symptoms related to hyperestrogenism are common at diagnosis.

Krukenberg tumour, also known as carcinoma mucocellulare, refers to the signet ring subtype of metastatic tumour to the ovary. The stomach followed by colon are the two most common primary tumours to result in ovarian metastases, pursued by the breast, lung, and contralateral ovary.

A rare tumour that is made up of more than one type of cell found in the gonads (testicles and ovaries), including germ cells, stromal cells, and granulosa cells. Gonadoblastomas are usually benign (not cancer), but they may sometimes become malignant (cancer) if not treated.

Molding allows the skull bones of the fetal head some mobility during the normal delivery of foetus as the skull changes its shape to accommodate passage through the mothers pelvis. However this does not occur in breach delivery where the skull is in circular shape. Babies born breech typically have craniofacial and limb deformations resulting from their in utero position. These babies characteristically have a long, narrow head, (“dolichocephaly” or “type 1”), with a prominent occipital shelf, redundant skin over the neck, overlapping lambdoidal sutures, and an indentation below their ears (from shoulder compression).

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%.

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

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. There are various risk factors for gestational diabetes including increasing age, ethnicity, previous still births etc.

Between 18-20 weeks of gestation is the best time to perform an ultrasound for the identification of any physical or anatomical abnormalities including neural tube defects.

Maternal serum screening for Down syndrome is best performed between 15-17 weeks of pregnancy and this screening includes analysis of alpha fetoprotein, estriol, and beta-HCG in maternal blood. Conducting tests on accurate dates is necessary to obtain reliable results.

Amniocentesis which is very accurate for the diagnosis of chromosomal anomalies including Down syndrome, is best performed between 16-18 weeks of gestation and it carries a risk of 1 in 200 for miscarriage. Rh negative women will need Rh D immunoglobulin (anti-D).

Chorionic villus sampling is best performed between 10-12 weeks of gestation and carries a 1 in 100 risk of miscarriage, this test is also very much accurate for diagnosis of chromosomal anomalies. Rh negative women need Rh D immunoglobulin (anti-D).

It is best to perform rubella screen before conception than during pregnancy, this is because rubella vaccine is not recommended to be given to a pregnant mother as its a live vaccine.

Oxytocin can also stimulate after pains that occur 2-3 following delivery.

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.

The biochemical and mechanical effects of progesterone and the enlarging uterus are responsible for some changes in lung function during pregnancy.

Progesterone increases the sensitivity of the respiratory centre to arterial carbon dioxide while also causing hyperaemia in the airway leading to nasal obstruction. As a result, minute ventilation and tidal volume increase by 50% to allow greater arterial oxygen saturation.

The enlarging uterus displaces the diaphragm upwards, and also limits the movement of the thoracic cage, thereby decreasing the functional residual capacity (FRC) and the expiratory reserve volume (ERV) by 20%.

Functional Expiratory Volume in 1 second (FEV1) and Forced Vital Capacity (FVC) remain unchanged in pregnancy.

Klinefelter syndrome is associated with testicular atrophy, eunuchoid body shape, tall, long extremities, female hair distribution and gynaecomastia. It is a common cause of hypogonadism seen during fertility workup.

Antenatal screening for rubella IgG is a routine recommended for all pregnant women at their first visit. All pregnant women who have a history of contact with rubella or any clinical features consistent with rubella –like illness should be screened for the presence of rising antibody titre and / or rubella specific IgM. Serological confirmation is mandatory for diagnosing rubella.
As in this case scenario, positive lgM for rubella indicates active rubella infection, in such cases it is recommended to repeat the test. If lgM is still positive, it confirms rubella infection. No further testing from another laboratory is required.
The risk for fetal infection and damage is higher if rubella infection occurs during the first trimester of pregnancy, which is 85% in the first two months of pregnancy and 50 -80% in the third month. Therefore, termination of pregnancy is usually recommended in this situation. NHIG has been used in trials for prophylaxis and prevention of congenital rubella syndrome after contact to a case with rubella infection, but the results have been discouraging, therefore, it is not advisable.
In the given case, rubella infection has been established already, so NHIG will not be of any benefit as primary prevention.
Rubella-containing vaccines like MMR vaccine is a live attenuated vaccine are contraindicated throughout pregnancy, it should be avoided; and women who remain susceptible to rubella should receive MMR vaccine postpartum.
Risk of fetal infection and/or fetal damage or for development of congenital rubella syndrome is related to the timing of maternal infection. Cases with Primary infection is found to be in higher risk
In cases of asymptomatic re-infection with a good history of previous positive serology, even though it is difficult to quantify, the risk of fetal infection has been reported to be < 5 percent. Congenital rubella syndrome following maternal re-infection is considered rare particularly if re-infection occurs after 12 weeks. If the clinical picture is typically of rubella or if possibility of previous immunity is inconclusive based on serology, then the risk is assumed to be the same as that of primary infection.

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.

Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.

Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously­ normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidy

Maternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two.