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.

For the foetus to pass through the vagina, the obstetric conjugate should be 11cm or greater. If the diameter is less than 10 cm then its better to perform C-section as the labour might not progress. All the other options favour a normal vaginal delivery.

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

Circulation in the foetus: 1. Deoxygenated fetal blood is conducted to the placenta via the two umbilical arteries. The umbilical arteries arise from the internal iliac arteries.
2. Gas exchange occurs in placenta.
3. Oxygenated blood from the placenta passes through the single umbilical vein and enters the inferior vena cava (IVC).
4. About 50% of the blood in the IVC passes through the liver and the rest bypasses the liver via the ductus venosus. The IVC also drains blood returning from the lower trunk and extremities.
5. On reaching the heart, blood is effectively divided into two streams by the edge of the interatrial septum (crista dividens) (1) a larger stream is shunted to the left atrium through the foramen ovale (lying between IVC and left atrium) (2) the other stream passes into right atrium where it is joined by blood from SVC which is blood returning from the myocardium and upper parts of body. This stream therefore has a lower partial pressure of oxygen.
6. Because of the large pulmonary vascular resistance and the presence of the ductus arteriosus most of the right ventricular output passes into the aorta at a point distal to the origin of the arteries to the head and upper extremities. The diameter of the ductus arteriosus is similar to the descending aorta. The patency of the ductus arteriosus is maintained by the low oxygen tension and the vasodilating effects of prostaglandin E2;
7. Blood flowing through the foramen ovale and into left atrium passes into the left ventricle where it is ejected into the ascending aorta. This relatively oxygen rich blood passes predominantly to the head and upper extremities.

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.

HPV Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18. HPV types16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

The Corpus Luteum is a temporary endocrine structure that secretes two steroid hormones: 1. Progesterone (17a Hydroxyprogesterone) and 2. Oestradiol. The corpus luteum also secretes Inhibin A. In the menstrual cycle if fertilisation doesn’t occur the corpus luteum stops secreting progesterone and degenerates into a corpus albicans. If fertilisation occurs hCG signals the corpus to continue progesterone production and it is then termed the corpus luteum graviditatis

Shoulder dystocia occurs when the fetal shoulder impacts on the maternal symphysis or sacrum during vaginal delivery. About 10% of babies with shoulder dystocia will suffer a brachial plexus injury, the most common one being Erb-Duchenne palsy. In Erb’s palsy, the upper nerve roots C5 and C6 are damaged due to excessive widening of the angle between the head and the shoulder. This causing temporary paralysis in the affected arm whereby the infant will present with its hand hanging limp by his side, internal rotation of the forearm, plus wrist and finger flexion. This sign is called the ‘waiter’s tip hand’. The palsy usually resolves spontaneously in a large proportion of cases.

It blocks the voltage gated sodium channels and reduce the influx of sodium ions preventing depolarization of the membrane and blocking the conduction of the action potential. The affinity of the receptor site in the sodium channels depends on whether it is resting, open or inactive.