Urethral syndrome is characterized by dysuria and pyuria in the presence of a negative culture for uropathogens. Frequency and urgency are often absent. The infecting organism is typically Chlamydia trachomatis although other organisms such as Urea plasma urealyticum and Mycoplasma species may be involve- Effective medication choices include doxycycline, ofloxacin, levofloxacin, and macrolides such as erythromycin and azithromycin.

-Amoxicillin
lavulanate  and cephalexin  are incorrect. These would cover gram-positive bacteria but it would not cover gram-negative bacteria nor bacteria without a cell wall, which are the most common causes of this condition.
– Metronidazole is best for treating anaerobic infections and protozoa such as trichomonas vaginalis, it would not be the best for treating this condition, given the most likely causes.
-Pyridium is a phenazopyridine often used to alleviate the pain, irritation, discomfort, or urgency caused by urinary tract infections. While it would be beneficial for symptomatic relief, it is unlikely to completely resolve this patient’s condition, given her recent history.

Clomiphene and/or Metformin are 1st line agents. Weight loss in the setting of subfertility is advised if BMI >30 kg/m2

Girls with Turner’s syndrome (45,X) are not at risk for malignancy. Patients with feminizing testicular syndrome with XY chromosome composition and patients with mixed gonadal dysgenesis are at risk for malignancy, and bilateral gonadectomy is performed.

PMS is a condition, which is associated with somatic, emotional and behavioural symptoms during the women menstruation. Oenothera biennis with the common name of “evening primrose” is containing a valuable fixed oil with commercial name of EPO. Evening primrose oil has two types of omega-6-fatty acid including linoleic acid (60%–80%) and γ-linoleic acid (8%–14%). Essential fatty acids are considered as essential compounds for body health, especially among women. Evening primrose oil’s is effective in women health, but the immediate response should not be expected from it, therefore, it should be regularly used up to 4 or 6 months.

Oral contraceptive pills are only used when other treatments fail.
SSRI are only indicated in cases of persistent mood changes like depression.
Local anaesthetics have no role in the management of PMS.

Some confusion regarding breast cancer screening arose in 2009 when the U.S. Preventive Services Task Force (USPSTF) issued new mammogram guidelines. The task force recommended that screening mammograms be conducted every two years, beginning at age 50, for women with an average risk of breast cancer. For women aged 40 to 49, the decision of whether to have annual mammograms should be based on a patient’s consideration of risks vs. benefits, according to the task force.

There is no evidence that frequent screening for women on HRT helps with early detection of malignancy.

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

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

The life time risk of breast cancer in BRCA 2 gene is 45% and of ovarian cancer is 15%.

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.

When symptoms are present, they may include abdominal pain, mass or swelling, and abnormal uterine bleeding. Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent. When abdominal pain is present, it usually is constant and ranges from slight to moderate in intensity.

Mucinous cystadenomas are relatively common (12% to 15% of all ovarian tumours). They can become massive. These tumours usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence.

Corpus luteal cysts present with irregular menses, abdominal fullness due to fluid build up and pelvic pressure.

Endometriosis mainly presents with cyclic pain at site of involvement and dysmenorrhea.

The drug of choice for eclampsia and pre-eclampsia is magnesium sulphate. It is given as a loading dose of 4g i/v over 5 minutes, followed by an infusion for the next 24 hours at the rate of 1g/hr. If the seizures are not controlled, an additional dose of MgSO4 2-4gm i/v can be given over five minutes. Patients with eclampsia or pre-eclampsia can develop any of the following symptoms: persistent headache, visual abnormalities like photophobia, blurring of vison or temporary blindness, epigastric pain, dyspnoea and altered mental status.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

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.

Congenital Herpes Simplex Virus infection may cause high levels of morbidity and mortality in neonates. Risk of infection with HSV 1 and 2 is highest within 6 weeks of delivery and is transferred to the neonate via maternal secretions at birth. Affected babies can present as skin manifestations, CNS infection, or disseminated infection, which carries an 85% risk of mortality if left untreated. Treatment with high dose antivirals such as acyclovir can help decrease the case mortality rate to 30% in cases of disseminated infection.

Counselling her about the risks associated with obesity during pregnancy will be the best possible advice to give this patient. A combined follow up by an obstetrician and a diabetes specialist at a high-risk pregnancy clinic is required to formulate the best ways in management of gestation with obesity.
An oral glucose tolerance test should be done at 26 weeks of her pregnancy, along with advising her on controlling her weight by diet and lifestyle modifications. During the early weeks of their pregnancy all obese patients must be routinely tested for pre-existing diabetes.

It is highly inappropriate to advice her not to get pregnant.

Without making a proper diagnosis of diabetes, it is wrong to ask her to start oral hypoglycemic agent and/or insulin.

Checking urinary proteins is not indicated at this stage, but can be considered as a part of antenatal check up.

The ovarian arteries, arising from the abdominal aorta and the ascending uterine arteries which are branches of the internal iliac artery all supply the ovaries. They terminate by bifurcating into the ovarian and tubal branches and anastomose with the contralateral branches providing a collateral circulation.

Pregnant women with high-grade squamous intraepithelial lesions (HSIL) on cervical cytology should be evaluated with colposcopy. Principles of management of pregnant women include the following:
– An immediate diagnostic excisional procedure should NOT be performed.
– When colposcopy is performed during pregnancy:
– Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy; however, the endocervical canal may be sampled gently with a cytobrush.
– Cervical biopsy should be performed only if a lesion is present that appears to be high grade or suspicious for cancer.
– If the examination is unsatisfactory, repeating the colposcopy after 6 to 12 weeks should allow visualization of the entire squamocolumnar junction.

There is no indication for inducing abortion or performing a hysterectomy.

Thelarche means appearance of the breast tissue under the influence of oestrogen from the ovaries. It heralds the onset of puberty among girls. It is followed by an increase in growth velocity followed by menarche which is the time of first menstrual bleeding.

It utilizes the IgG class of the antibody.

Pre-eclampsia presents with other features in addition to the presence of hypertension, also it’s diagnosis cannot be made considered peripheral edema as the only presenting symptom. Proteinuria occurs more commonly in pre-eclampsia than in gestational hypertension and the latter is mostly asymptomatic.

Hypertensive disorders are found to complicate about 10% of all pregnancies. Common one among them is Gestational hypertension, which is defined as the new onset of hypertension after 20 weeks of gestation without any maternal or fetal features of pre-eclampsia, in this case BP will return to normal within three months of postpartum.

Types of hypertensive disorders during pregnancy:
1. Pregnancy-induced hypertension:
a. Systolic blood pressure (SBP) above 140 mm of Hg and diastolic hypertension above 90 mmHg occurring for the first time after the 20th week of pregnancy, which regresses postpartum.
b. The rise in systolic blood pressure above 25 mm of Hg or diastolic blood pressure above 15 mm of Hg from readings before pregnancy or in the first trimester.
2. Mild pre-eclampsia:
BP up to 170/110 mm of Hg in the absence of associated features.
3. Severe pre-eclampsia:
BP above 170/110 mm of Hg and along with features such as kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise.
4. Essential (coincidental) hypertension:
Chronic underlying hypertension occurring before the onset of pregnancy or persisting after postpartum.
5. Pregnancy-aggravated hypertension:
Underlying hypertension which is worsened by pregnancy.

To diagnose pre-eclampsia clinically, presence of one or more of the following symptoms are required along with a history of onset of hypertension after 20 weeks of gestation.
– Proteinuria: Above 300 mg/24 h or urine protein
reatinine ratio more than 30 mg/mmol.
– Renal insufficiency: serum/plasma creatinine above 0.09 mmol/L or oliguria.
– Liver disease: raised serum transaminases and severe epigastric or right upper quadrant pain.
– Neurological problems: convulsions (eclampsia); hyperreflexia with clonus; severe headaches with hyperreflexia; persistent visual disturbances (scotomata).
– Haematological disturbances like thrombocytopenia; disseminated intravascular coagulation; hemolysis.

Prelabour Rupture of Membranes:
– Risk of serious neonatal infection 1% (vs 0.5% for women with intact membranes)
– 60% of patients with PROM will go into labour within 24 hrs
– Induction appropriate if >34 weeks gestation and >24 hours post rupture and patients labour hasn’t started.
– If <34 weeks induction of labour should not be carried out unless there are additional obstetric indications e.g. infection

In this case, the patient has a missed abortion, which is defined as a dead foetus or embryo without passage of tissue and with a closed cervix. This condition often presents with failure to detect fetal heart tones or a lack of growth in uterine size.

– By 14 weeks estimated gestational age, fetal heart tones should be detected by both handheld Doppler and ultrasonography.
– An inevitable abortion presents with a dilated cervix, but no passage of fetal tissue.
– A blighted ovum involves failure of the embryo to develop, despite the presence of a gestational sac and placental tissue.

The following are the most common symptoms for endometriosis, but each woman may experience symptoms differently or some may not exhibit any symptoms at all. Symptoms of endometriosis may include:

Pain, especially excessive menstrual cramps that may be felt in the abdomen or lower back
Pain during intercourse
Abnormal or heavy menstrual flow
Infertility
Painful urination during menstrual periods
Painful bowel movements during menstrual periods
Other gastrointestinal problems, such as diarrhoea, constipation and/or nausea

All options can be symptoms of endometriosis but the commonest one is dysmenorrhea.

Congenital Adrenal Hyperplasia leads to the virilization of the foetus. It occurs due to an enzyme deficiency in the corticosteroid production pathway i.e. 21-hydroxylase which converts progesterone to deoxycorticosterone. The reduced levels of corticosteroids results in the negative feedback loop that leads to adrenal hyperplasia.

The incidence of listeria infection in pregnant women is estimated at 12 per 100 000 compared to 0.7 per 100 000 in the general population.

Endometriosis is a condition in which the endometrial tissue lies outside the endometrial cavity. There are 4 theories which explain this. First is pathological hyperplasia resulting in menstrual regurgitation and implantation, second is the coelomic epithelium transformation, third is immunogical factors and the fourth is via the lymphatic or vascular spread.

Traditional POP main mode of contraceptive action: thickening of cervical mucus Desogestrel-only POP main mode of contraceptive action is inhibition of ovulation Cerazette® is the only Desogestrel-only POP in the options above. Other desogestrel brands include: Aizea® Cerelle® Nacrez® The other POPs listed are considered traditional POPs and have the following compositions: Norgeston® – Levonorgestrel 30 mcg Micronor® & Noriday® – Norethisterone 350 mcg Femulen® – Ethynediol diacetate 500 mcg

The common route of metastases of the ovarian cancer is transcoelomic route.

The Mantoux test is based on type IV hypersensitivity reaction.

The commonest foetal presentation in twin pregnancy is cephalic-cephalic.

A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.