The clinical picture demonstrated is most likely that of a ruptured ectopic pregnancy. The period of amenorrhea may point to pregnancy, while the past medical history of 2 recent terminations of pregnancy may indicate a failure of her current contraceptive method. Smoking cigarettes have been shown to not only decrease the efficacy of OCPs, but also serve as a known risk factor for ectopic pregnancy. The lady is unlikely to have endometritis as her last termination was over 6 months ago. The lack of fever helps to make appendicitis, PID and pyelonephritis less likely, though they are still possible.

In pregnancy, term refers to the gestational period from 37 0 to 41 6 weeks. Preterm births occur between 24 0 and 36 6 weeks. 60% of the women will go into labour with in 24 hours in PPROM. After 24 hours have past without any contraction and the gestation age is more than 34 week than prostaglandins can be used to augment labour.

World Health Organization (WHO) Group I ovulation disorder is due to hypothalamic pituitary failure. This is sometimes termed hypothalamic amenorrhoea or hypogonadotropic hypogonadism. Women can improve frequency of ovulation, conception and an uncomplicated pregnancy by increasing their body weight (if BMI of <19) and/or moderating their exercise levels (if they undertake high levels of exercise). GnRH and LH may be administered in these patients. PCOS falls under type II ovulation disorders. WHO Group III ovulation disorder is due to ovarian failure.

If the external anal sphincter is in tact then this is a 1st or 2nd degree tear. As the perineal muscles are involved this is 2nd degree tear.

The production of milk is regulated by the hormone Prolactin. Oxytocin on the other hand is responsible for the let down reflex that occurs during breast feeding.

Progesterone gradually increases during the course of pregnancy, from 25 ng⋅mL−1 at 6 weeks’ to 150 ng⋅mL−1 at 37 weeks’ gestation. Progesterone acts as trigger of the primary respiratory centre by increasing the sensitivity of the respiratory centre to carbon dioxide, as indicated by the steeper slope of the ventilation curve in response to alveolar carbon dioxide changes. Progesterone alters the smooth muscle tone of the airways resulting in a bronchodilator effect. It also mediates hyperaemia and oedema of mucosal surfaces, causing nasal congestion.

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

Hysterosalpingography is a radiological test used to investigate infertility especially in patients with no history suggesting tubal blockages such as pelvic surgery or PID, in which case a laparoscopy and dye is better suited. For the procedure, a contrast dye is inserted through the cervix, flows through the uterus and the fallopian tubes and should spill into the peritoneum. Fluoroscopy provides dynamic images of these structures to determine if there are any abnormalities or blockages. HSG is best performed on day 6-12 in the cycle, after the cessation of menses, and before ovulation, to avoid X Ray exposure in case of an unknown early pregnancy.

The most common treatment approach is with the dopamine receptor agonists, bromocriptine, and cabergoline. Bromocriptine normalizes prolactin and decreases tumour size in 80%–90% of patients with microadenomas. Bromocriptine should be given to this patient who has developed hyperprolactinemia anovulation.

Women with hyperprolactinaemic anovulation are treated with dopamine agonists such as bromocriptine.
This patient has also developed symptoms of a low-functioning pituitary gland tumour, which bromocriptine will assist to shrink. Before starting bromocriptine, a head MRI scan should be considered to confirm the suspected diagnosis.

Clomiphene is an oestrogen receptor modulator that is selective. It works by competing with oestrogen receptors in the hypothalamus. This disrupts normal negative feedback mechanisms, causing the release of pituitary gonadotropins, particularly LH, to rise, triggering ovulation.
When the levels of gonadotropins and oestrogen are normal but the women still have ovulatory dysfunction, it is successful in inducing ovulation. In hypogonadotropic hypogonadism and hypogonadotropic hypogonadism patients, clomiphene is frequently ineffective.

Androgen insensitivity syndrome means that patients are phenotypically males but they are resistant or insensitive to male androgen hormones. They do not have a uterus. Due to insensitivity to androgens these patients often have female traits but their genetic makeup is of male, 46XY.

Human chorionic gonadotrophin (hCG) has thyrotrophic activity owing to subunit homology with thyroid-stimulating hormone (TSH) and maternal TSH production is suppressed during the first trimester of pregnancy, when hCG levels are highest. The TSH response to thyrotrophin-releasing hormone (TRH) is reduced during the first trimester but returns to normal after this. Thyroid binding globulin increases in the first 2 weeks of pregnancy and reaches a plateau by 20 weeks. This leads to increased production of total T3 (tri-iodothyronine) and T4 (thyroxine).

The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

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.

The best method to provide symptomatic relief to this woman is to use pressure stockings and a vulval pad (correct answer). This will provide relief without causing any adverse effects.

In order to prevent ulceration, care is required to avoid trauma.

Since the patient is pregnant, surgical ligation or injecting of sclerosing solutions cannot be considered and are contraindicated.

Development of varices is often exacerbated in subsequent pregnancies; and therefore surgery should be eschewed until child-bearing is complete,

Bed rest in hospital would reduce the symptoms of the varicose veins; however this should be avoided as it can increase the risk of developing deep vein thrombosis.

Anticoagulant therapy has not been shown to be beneficial for treatment of varicosities that only affect the superficial venous system and should therefore not be used.

Repetitive late decelerations can be caused by fetal hypoxia which results in constriction of the vessels to circulate blood from the peripheries to more important organs of the body like the brain and heart etc.

Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending foetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability.

Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities.

The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse.

In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. The definitive management of umbilical cord prolapse is expedient delivery; this is usually by caesarean section.

Tubal sterilization is a safe and effective surgical procedure that permanently prevents pregnancy. However, pregnancy can occur in 1 in 200 cases, according to international sources. In the 1st year after tubal sterilization, the estimated failure rate is 0.1-0.8% respectively.

The syndrome with which the woman was diagnosed is an autoimmune, hypercoagulable state which most possibly was the reason of her previous miscarriages. This is the reason why she should be on aspirin and heparin in order to prevent any future miscarriage.

Evidence is not yet of sufficient quality for there to be evidence-based guidelines or recommendations. Having excluded other causes:

Reassure patients that breakthrough bleeding is a common side-effect of CHC and usually resolves after three cycles of use.
Advise women who smoke that stopping smoking may improve cycle control.
If bleeding persists after three cycles, consider changing formulation:
Increase dose of oestrogen, particularly if on a 20-microgram ethinylestradiol (EE) preparation

All other options are not acceptable.

The ovarian arteries are considered the main blood supply for the ovaries. The ovarian arteries usually arise from the lateral aspect of the abdominal artery, though in some instances they may arise from the renal or iliac arteries.

Majority of the lymph from the ovaries drain into the para-aortic lymph nodes.

Dehydroepiandrosterone is an androgen precursor produced primarily by the adrenal glands in women. The steroid hormone is produced from cholesterol at birth by the fetal adrenal glands, after which its output reduces. DHEA production picks up again from the age of 5-7 years and peaks between the ages of 20-30.

Ovulation occurs in the mid stage of the menstrual cycle, usually 36 hours after the LH surge. It is this LH surge which is necessary for the ovulation to occur.

Although uterine growth during the first few weeks of pregnancy is accomplished by increased numbers of smooth muscle cells (i.e. hyperplasia) and a smaller contribution from increased cell size (i.e. hypertrophy), the predominant growth of the uterus during pregnancy is by way of stretch‐induced myometrial hypertrophy. This ongoing process of stretch‐induced tissue remodelling and smooth muscle hypertrophy is accompanied by the lack of uterine contractions during most of gestation to accommodate the developing foetus (phase 0 of parturition). Phase 1 of parturition represents myometrial activation. The final stages of pregnancy are characterized by increases in spontaneous low‐amplitude contractions that gradually increase in frequency, rhythmicity and strength, normally culminating in labour and delivery of the foetus at term (phase 2 of parturition).

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.

Calcium phosphate salts are the most abundant form of calcium in the body, making up 99%. The majority of these salts are stored in the skeleton in different forms, mostly, hydroxyapatite, a lattice-like crystal composed of calcium, phosphates and hydroxide. The remaining calcium can be found in the extracellular fluid, tissues and skeletal muscle.

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.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 week old and is replaced by adult haemoglobin by the age of 5 months post natally. Only 2% of the haemoglobin is HbF.

Embryonic Haemoglobin:
Haemoglobin Gower 1 (HbE Gower-1)
Haemoglobin Gower 2 (HbE Gower-2)
Haemoglobin Portland I (HbE Portland-1)
Haemoglobin Portland II (HbE Portland-2)

Fetal Haemoglobin (haemoglobin F, HbF)

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.

History of heavy menstrual bleeding and amenorrhoea favour the diagnosis of a fibroid uterus. All the given responses are causes for subfertility. Ectopic pregnancy presents with abdominal pain has an acute presentation. Endometriosis and adenomyosis usually don’t present with amenorrhoea or heavy bleeding respectively. PID presents with chronic pelvic pain and is not related to menstruation.