The clinical features of endometriosis include dyspareunia, dysmenorrhea, dysuria, dyschezia as well as infertility. Pain is characteristically long-term, cyclic (often occurring the same time as menses) and can get progressively worse over time. Laparoscopy remains the standard for diagnosis. There are many cases in which endometriosis is only discovered at the time of the workup for infertility.

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).

The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.

Perineal tears are common at the time of child birth. First degree perineal laceration means that the wound is so small that it doesn’t require any stitches and usually heals on its own. 2nd degree means that skin and smooth muscles are both torn. 3rd degree tear means that the tear is beyond the perineal muscles and the muscles surrounding the anal canal, while in 4th degree, the perineal tear goes through the anal sphincter up to the rectum.

Most women lose about 35-40 ml of blood on average during each menstrual cycle. The maximum amount of blood loss is 80 ml after which blood loss of more than 80 ml is defined as heavy menstrual bleeding, formerly known as menorrhagia.

This patient should have an endometrial biopsy (SOR C). Approximately 7% of postmenopausal women with benign endometrial cells on a Papanicolaou smear will have significant endometrial pathology. None of the other options listed evaluate the endometrium for pathology. An asymptomatic premenopausal woman with benign endometrial cells would not need an endometrial evaluation because underlying endometrial pathology is rare in this group.

The best treatment option for chlamydial urethritis in pregnancy is Azithromycin 1g as a single dose orally. This is the preferred option as the drug is coming under category B1 in pregnancy.

Tetracycline antibiotics, including doxycycline, should never be used in pregnant or breastfeeding women.

Erythromycin Estolate is contraindicated in pregnancy due to its increased risk for hepatotoxicity. Ciprofloxacin is not commonly used for treating chlamydial urethritis and its use is not safe during pregnancy.

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.

Cholesterol is the common precursor for progesterone and androgen production.

Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.

Fetal hypoxia may cause absent, increased or decreased variability. Other causes of decreased variability include: normal fetal sleep-wake pattern, prematurity and following maternal administration of certain drugs including opioids.

Variability Range:
Normal – 5 bpm – 25bpm
Increased – >25 bpm
Decreased – <5 bpm
Absent – <2 bpm

In hyperemesis gravidarum, IV corticosteroids can be given to reduce vomiting, if the patient is not responding to standard anti emetics.

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.

There is high possibility of her being pregnant. Urine B-hCG has to be checked to exclude pregnancy.

Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.

The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic
henodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.

Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta- Mild elevation of gamma glutamyl transferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.

IUCD is a risk factor for PID and PID has the clinical picture already described. However, fibroids should also be excluded since they may present in the same way.

The most suitable step would be to wait for spontaneous onset of labour. This woman would be able to deliver vaginally in 3 situations. The first would be if the foetus is estimated to weigh less than 3800g (first child weight 3800g). Another would be if the foetus is in a frank or complete breech presentation and lastly if the rate of labour progress is satisfactory and breech extraction is unnecessary. RCOG (Royal College of Obstetricians & Gynaecologists) guidelines recommends that women should be informed that elective Caesarean section for the delivery of a breech baby would have a lower risk of perinatal mortality than a planned vaginal delivery. This is because with an elective Caesarean section, we would be able to avoid stillbirth following 39 weeks of gestation as well as intrapartum and vaginal breech delivery risks. The ideal mode of delivery of a breech foetus when labour starts or at least close to term is a Caesarean section as the risks towards the foetus would be significantly increased in a vaginal delivery. The obstetrician is responsible to ensure that there are no other abnormalities that could complicate this even further such as footling presentation, low estimated birth weight (less than 10th centile), hyperextended neck on ultrasound, evidence of fetal distress and high estimated birth weight (>3.8kg). Provided that there is a normal progression of events, fetal risks during both labour and delivery should be low if such factors are absent. Hence, it is right to await the onset of labour to occur spontaneously in this case. In order to exclude a knee presentation with fetal head extension or a footling breech, ultrasound examination has to be done. These are linked to a high fetal risk if the mother attempts vaginal delivery. X-ray pelvimetry is advisable but is not essential in fetal size assessment since its accuracy is roughly 20%. In this case, it is not indicated since there is evidence that her pelvis is of adequate size as she had already delivered a 3.9kg baby prior. It is best to avoid induction of labour in breech cases for numerous reasons (need for augmentation, cord prolapse).

(13-20 weeks). If a mother has chickenpox in late pregnancy (5 days prior to delivery) then there is risk of neonatal varicella infection which may be severe.

Macrophages are derived from monocytes. When monocytes come across a pathogen they differentiate into macrophages for phagocytosis to occur.

This patient should be advised to use both an OCP and a condom. The combined oestrogen/progestogen contraceptive pill (COCP) has been found to be very effective. However, she should be made aware that it would not provide any protection from any sexually transmitted diseases so she might still be at risk of developing a STD, depending on her sexual partner preferences. To ensure protection from STDs, she should be advised to use both condoms as well as the combined OCP. An IUCD (intrauterine contraceptive device) would not be preferable if she has multiple sexual partners (high risk of STDs). If she has been screened for STDs, does not actively have an STD and has only one sexual partner then IUCD is a possible option. Some issues that may arise with spermicide use could be related to compliance. This also applies to using condoms alone. These two options are less reliable as compared to COCP.

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.

There are four types pelvic shapes:
1) Android pelvis: it has a larger inlet and smaller outlet along with small posterior sagittal diameter, prominent ischial spines and has a two finger arch.
2) Gynecoid pelvis: it has a transverse or nearly a circular ellipse and it is the most favourable for delivery.
3) Anthropoid pelvis: the brim is an anteroposterior ellipse.
4) Platypelloid pelvis: in this type the pelvic brim is kidney shape

Breast feeding facilitates the production of Oxytocin by the hypothalamus which is stored and secreted by the posterior pituitary.
Ergometrine is an ergoline derivative that can be used to increase uterine tone.
Atosiban is an antagonist of Oxytocin receptors
ADH is another posterior pituitary hormone.
Prostaglandin E2 plays an important role in cervical ripening.

CMV effects 1 in 200 pregnancies of which 30% will transmit the virus to the foetus and of which 30% foetus will be effected.

Increasing sample size decreases type 2 errors and increases power of the results. Sensitivity and specificity of the test should remain constant regardless of sample size. Confidence intervals are applied by a statistician and are dependent on the mean.

During follicular phase, there is an increase in gonadotrophin hormones and a proliferation of the endometrium occurs. The duration of the cycle depends upon the overall length of the menstrual cycle. The progesterone levels are increased in the luteal phase and not in follicular phase.

IgM rise is typically seen with acute infection. IgG is produced in response to infection but is produced later than IgM. IgG is also produced in response to vaccination. If IgG and IgM are negative the patient is susceptible to Rubella infection. If IgG +ve and IgM -ve the patient should be considered immune. If IgM +ve this suggests acute infection or false positive IgM (not uncommon)

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.

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.

Engagement means when the fetal head enters the pelvic brim/inlet and it usually takes place 2 weeks before the estimated delivery date i.e. at 38 weeks of pregnancy.