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.

Gestational trophoblastic disorder is characterized by an abnormal trophoblastic proliferation and include a complete and partial mole. It is characterized by persistently elevated BHCG levels after pregnancy and on ultrasound a snow storm appearance. These appear as anechoic areas on ultrasound.

Sodium Valproate is known to be the most teratogenic when used in the first trimester of pregnancy. This antiepileptic increases the risk of congenital malformations including a 10-20 fold risk of neurodevelopmental defects. Though the use of antiepileptics should generally be avoided during pregnancy, carbamazepine, or newer drugs such as Lamotrigine are thought to carry less of a risk of teratogenicity.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

Postinor-2 (levonorgestrel 750pg) is only an emergency contraceptive and is not designed to be a regular form of contraception. If taken within 24 hours, it is estimated to be able to prevent up 97-98% of pregnancies and 58% if given between 48-72 hours post-unprotected intercourse. It can cause vaginal bleeding within a few days of its administration if it is given before day 8-10 of her menstrual cycle. However, if given mid-cycle, it typically doesn’t affect the timing of her next period unless conception occurs. Nausea and vomiting were common when high doses of OCP were used as a post-intercourse contraceptive. Nausea and vomiting still can occur with Postinor-2, but not up to 50% of women. There is currently no evidence to suggest that the levonorgestrel dose would cause a virilising effect on female foetuses.

CAH leads to virilization of the female foetus. It occurs to an enzyme deficiency (21-hydroxylase). This results in a reduced levels of corticosteroids from being circulated resulting in hyperplasia of the adrenal glands and increased progesterone production. The CYP21A gene has been implicated in causes this deficiency.

Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective hormonal contraceptives for obese women because they do not appear to be affected by body weight. Women using the combination contraceptive patch who weight 90 kg may experience decreased contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of pregnancy.

The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.

Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.

The diagnosis of listeria depends on clinical suspicion and isolation of the organism from blood, vaginal swabs or the placenta. Meconium staining of the amniotic fluid in a preterm foetus may increase clinical suspicion for listeriosis. For women with listeriosis during pregnancy, intravenous antibiotic treatment (ampicillin 2 g given every 6 hours) is indicated.

The most likely cause of her postcoital bleeding is cervical ectropion as suggested by her postcoital bleeding, normal pap smears and use of oral contraceptive pills.

Cervical ectropion is a benign condition that occurs as a result of overexposure to oestrogen. Here, glandular cells (the columnar epithelium) lining the endocervix, begin to grow on the ectocervix, leading to exposure of the columnar cells to the vaginal environment.

These columnar cells are prone to trauma and bleeding during coitus.

Fibroids are a common gynaecological condition found in many women above the age of 35. They are however uncommon before puberty. They are most common in black women vs white women, and its prevalence increases from puberty to menopause. Risk factors for fibroids include increasing age, obesity and infertility. Protective factors, on the other hand, include pregnancy, as the risk of fibroids decreases with increasing numbers of pregnancies.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.

Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).

Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.

Hormones that increase during pregnancy and their roles:

1. Human Chorionic Gonadotropin (hCG): Peaks between the eighth to tenth weeks of gestation and supports the corpus luteum to maintain progesterone production.
2. Progesterone: Initially produced by the corpus luteum and later by the placenta, it rises steadily throughout pregnancy, suppressing the maternal immune response to fetal antigens and preparing the endometrium for implantation.
3. Estrogen: Produced by the placenta from fetal and maternal precursors, estrogen levels increase to promote uterine growth and blood flow.
4. Human Placental Lactogen (hPL): Rises significantly during pregnancy, influencing maternal metabolism by increasing insulin resistance and promoting lipolysis.
5. Relaxin: Increases early in pregnancy to relax the uterine muscles, inhibit contractions, and prepare the cervix and pelvis for childbirth.
6. Prolactin: Levels increase to prepare the breasts for lactation.
7. Corticotropin-Releasing Hormone (CRH): Increases towards the end of pregnancy and is involved in the timing of labor.
8. Adrenocorticotropic Hormone (ACTH): Levels increase, contributing to elevated cortisol levels during pregnancy.
9. Total Thyroxine (T4): Levels increase due to elevated thyroid-binding globulin (TBG) production stimulated by increased estrogen levels, meeting the increased metabolic demands of pregnancy.
10. Parathyroid Hormone (PTH): Levels increase to regulate calcium metabolism, ensuring adequate calcium for fetal bone development.
11. Cortisol: Levels increase due to higher production by the adrenal glands and increased binding to cortisol-binding globulin (CBG), supporting glucose metabolism, managing stress, and aiding fetal development, particularly lung maturation.

During pregnancy, some hormones either remain stable or do not increase significantly. These include:

1. Follicle-Stimulating Hormone (FSH): Levels decrease due to the negative feedback from high levels of estrogen and progesterone.
2. Luteinizing Hormone (LH): Levels also decrease due to negative feedback from elevated estrogen and progesterone.
3. Growth Hormone (GH): Although a variant of growth hormone (hGH-V) is produced by the placenta and increases, the maternal pituitary GH levels may not significantly increase.
4. Melatonin: Generally remains stable during pregnancy, though some studies suggest there may be slight fluctuations.
5. Insulin: While insulin resistance increases due to hPL and other factors, the actual levels of insulin may not increase proportionally; instead, pancreatic beta-cell function adapts to meet the increased demand.

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.

Causes of Hyperprolactinemia: Prolactinomas, Medication (phenothiazines, metoclopramide, risperidone, selective serotonin reuptake inhibitors, oestrogens, verapamil), Stress, Pregnancy, Hypothyroidism, Kidney disease, Chest trauma

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.

Twin pregnancies are at risk for iron deficiency due to significant maternal, fetal, and placental demands. Recommendations regarding the optimal iron dose in twin pregnancies are based on clinical expert opinions, advocating doubling the dose of iron from 30 mg of elemental iron to 60 mg routinely during the second and third trimester, regardless of maternal iron stores.

If pregnant with twins, patient should take the same prenatal vitamins she would take for any pregnancy, but a recommendation of extra folic acid and iron will be made. The additional folic acid and extra iron will help ward off iron-deficiency anaemia, which is more common when patient is pregnant with multiples.

Detrusor overactivity can be treated with anti-cholinergic agents such as oxybutynin or tolterodine, solifenacin, fesoterodine and darifenacin. They are used as first line agents. Imipramine is used for enuresis and desmopressin is used for nocturia.
NICE pathway

Prior to initiating anticholinergics:
Bladder training
Consider treating vaginal atrophy and nocturia with topical oestrogen and desmopressin respectively before commencing treatments below.
Consider catheterisation if chronic retention
1st line treatments:
1. Oxybutynin (immediate release) – Do not offer to frail elderly patients
2. Tolterodine (immediate release)
3. Darifenacin (once daily preparation)
DO NOT offer any of the 3 drugs below:
1. Flavoxate
2. Propantheline
3. Imipramine
2nd line treatment
Consider transdermal anticholinergic (antimuscarinic)
Mirabegron
Adjuvant Treatments
Desmopressin can be considered for those with nocturia
Duloxetine may be considered for those who don’t want/unsuitable for surgical treatment
Intravaginal oestrogen can be offered to postmenopausal women with OAB

In stage III cervical cancer there is involvement of the pelvic wall and ureter which may result in abdominal pain and hydronephrosis.

2010 FIGO classification of cervical carcinoma

Stage
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, Greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis
4A – Invades mucosa bladder and rectum
4B – Distant Metastasis

Oesophageal atresia of the foetus interrupts the normal circulation of the amniotic fluid. This causes polyhydramnios and subsequent distension of the uterus impacting proper expansion of the lungs. This would explain the difficulty breathing.

Phosphate and ammonia are the major urinary buffers

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.

This patient meets the diagnostic criteria for premenstrual syndrome.
Affective and somatic symptoms over the five days before menses in each of the three previous menstrual cycles are diagnostic criteria for premenstrual syndrome.
Affective symptoms include:
– Depression.
– Anger outbursts.
– Irritability.
– Anxiety.
– Confusion.
– social withdrawal.
Somatic symptoms include:
– breast tenderness
– abdominal bloating
– headache and swelling of extremities.
Symptoms normally disappear within four days of menstruation and are present even when no medical therapy, drugs, or alcohol are used.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent crying, loss of interest in daily activities, reduced focus, exhaustion, sleeplessness, and a sense of being overwhelmed or out of control.
Symptoms must have been present for the majority of the previous 12 months, interfering with daily activities.

The diagnoses of generalised anxiety disorder and depression alone are doubtful.

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.

A normal pH value is above 7.25. A pH below 7.20 is confirmation of fetal compromise. Values between 7.20 and 7.25 are ‘borderline’.

The base deficit can also be useful in interpretation of the fetal scalp pH. A base excess of more than -10 demonstrates a significant metabolic acidosis, with increasing risk of fetal neurological injury beyond this level. Delivery should be considered.

Most common risk factors for spontaneous abortion are considered to be:
– Age above 35 years.
– Smoking.
– High intake of caffeine.
– Uterine abnormalities like leiomyoma, adhesions.
– Viral infections.
– Thrombophilia.
– Chromosomal abnormalities.
Conditions like subclinical thyroid disorder, subclinical diabetes mellitus and retroverted uterus are not found to cause spontaneous abortions.
The term retroverted uterus is used to denote a uterus that is tilted backwards instead of forwards.

Level I: Evidence obtained from at least one properly designed randomized controlled trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Premenstrual dysphoric disorder (PMDD) is a more serious form of premenstrual syndrome (PMS). PMS causes bloating, headaches, and breast tenderness a week or two before your period.

With PMDD, you might have PMS symptoms along with extreme irritability, anxiety, or depression. These symptoms improve within a few days after your period starts, but they can be severe enough to interfere with your life.

PMDD symptoms appear a week or two before menstruation and go away within a few days after your period starts. In addition to PMS symptoms, you may have:

Anger or irritability.
Anxiety and panic attacks.
Depression and suicidal thoughts.
Difficulty concentrating.
Fatigue and low energy.
Food cravings or binge eating.
Headaches.
Insomnia.
Mood swings.

The following treatments have been shown to relieve symptoms:

Sertraline, escitalopram, paroxetine, and fluoxetine are SSRIs (selective serotonin reuptake inhibitors). SSRIs are the first-line treatment and are extremely effective.
The second line of defence is alprazolam (a short course recommended due to its addictive potential).
The use of temazepam has little advantage because it only aids with sleep and is relatively short-acting.
Lifestyle modifications-weight loss, exercise, quitting smoking, and relaxation therapies for less severe PMS.
Danazol-suppresses the ovulation and helps with mastalgias associated with PMS.

Nerve Supply: L5 to S2 via Nerve to Piriformis
Origin: Sacrum
Insertion: Greater trochanter
Action: External rotation of hip
Blood Supply: Superior and Inferior gluteal arteries and lateral sacral arteries

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

Stillbirth has many causes: intrapartum complications, hypertension, diabetes, infection, congenital and genetic abnormalities, placental dysfunction, and pregnancy continuing beyond forty weeks.

In 5% of normal-appearing stillborns, a chromosomal abnormality will be detectable. With an autopsy and a chromosomal study, up to 35% of stillborns are found to have a major structural pathology, and 8% have abnormal chromosomes. After a complete evaluation, term stillbirth remains unexplained about 30% of the time. The chance of finding a cause is impacted by the age of the foetus, the experience of the caregiver, and the thoroughness of the exam. Chromosome testing for aneuploidy should be offered for all stillbirths to confirm or to seek a cause of the stillbirth. Genetic amniocentesis or chorionic villus sampling before delivery offers the highest yield.

Trichomoniasis is considered a sexually transmitted infection found both in men and women caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis for a HIV positive woman who is pregnant is 500mg of metronidazole twice daily for 7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated, and screening for other STIs should be carried out.

Abdominal hysterectomy is performed through a Pfannenstiel incision. There are certain complications associated with hysterectomy including haemorrhage, injury to the ureter(1%) and less commonly bladder and bowel (0.04%).

Normal menstrual blood loss is about 40-45 ml. More than 80 ml per period is defined as heavy menstrual bleeding.

Sertoli cells contain receptors for FSH. In response to this Sertoli cells synthesize inhibin, androgen binding proteins and anti Mullerian hormone all which are connected to the reproduction cycle.

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

This is one of the defects attributable to Carbimazole use.

Fetal position and presentation is best evaluated by Leopold’s manoeuvre. It will determine which part of the foetus is in the uterine fundus.
Cullen’s sign is found in ruptured ectopic pregnancy characterised by bruising and oedema of the periumbilical region.
Mauriceau-Smelli-Veit manoeuvre is done during a breech delivery.

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

Meconium first appears in the fetal ilium at 10-16 weeks.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor.

These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

All other options are incorrect.

A brow presentation in a nulliparous woman is associated with high risk of obstructed labour and the need for delivery by Caesarean section.

Brow presentation occurs when the presenting part of the fetal head is the part between the orbital ridge and anterior fontanelle.

In multiparous women, the indications differ as vaginal manipulation or spontaneous flexion to a vertex presentation or extension to a face presentation can occur after full cervical dilatation.

Early fetal heart decelerations are indicative of a mild abnormality on cardiotocograph (CTG). It does not indicate obstructive labour or need for delivery by Caesarean section.

The slow descent of the fetal head can be controlled subsequently by good uterine contractions and allow for vaginal birth.

Prolonged labour can cause maternal fever, but that in isolation is not an indication for Caesarean section.

Caput and head moulding are associated with a ‘tight fit’ of the fetal head in the pelvis, but does not contraindicate vaginal birth.

The maxillary arteries and the external carotid arteries develop from the first pharyngeal arch. The stapedial arteries arise from the second, the common carotid artery and the internal carotid arteries from the third and the arch of the aorta and the right subclavian artery from the forth arch.

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.

Congenital uterine abnormalities are associated with an increased risk of spontaneous abortions, preterm delivery of the foetus, fetal growth retardation and malpresentation.

The ureters receive innervation by a number of nerve plexuses. The nerves supplying the ureters originate from spinal segments T11 to L2. When you think about ureteric colic giving classic ‘loin to groin’ pain it is because the pain is referred to these dermatomes.

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

Because of the high possibility of spontaneous resolution and the fact that if the cystic mass was verified ultrasonically, a conservative policy would almost probably be proposed for at least another six weeks, an ultrasound examination is not necessary at this time. If the cyst is still present at the six-week check, an ultrasound examination is required, as it is likely that the cyst is a benign tumour or possibly endometriosis. It’s quite improbable that it’s cancer.
Additional tests, such as computed tomography (CT) examination and potentially surgical removal or drainage, may be required in the future, although not at this time.
This cyst in a young lady is almost probably of physiological origin, especially given its size. The woman should be informed, but a follow-up examination is required. The most suitable next action is to return in six weeks, as the cyst is most likely physiologic and will most likely dissipate naturally by then. The following appointment should not take place during the same menstrual cycle.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

Yasmin has been linked to decreased fluid retention and weight gain as a side effect of COCs, which is why most women who experience this side effect prefer Yasmin®.
Due to its anti-mineralocorticoid properties, drospirenone, unlike earlier progestogens, is associated with no weight gain or even moderate weight loss.
Yasmin has a similar failure rate to other COCs. No evidence using Yasmin is linked to a lower risk of cervical cancer as a long-term side effect of COCs. Yasmin, like all COCs, can cause spotting and irregular bleeding in the first few months of use.
Drospirenone, a progesterone component, has antiandrogenic properties and is slightly more successful in treating acne, but the difference is not big enough to make it preferable in terms of acne therapy or prevention when compared to other COCs.

The Rhesus status of a mother is important in pregnancy and even abortion. The exposure of an Rh-negative mother exposed to Rh antigens from a positive foetus, will influence the development of anti-Rh antibodies. This may cause problems in subsequent pregnancies leading to haemolysis in the newborn. Rh Anti RhD- globulin is therefore given to non-sensitised Rh-negative mothers who give birth to Rh-positive children to prevent the formation of anti-Rh antibodies. Anti RhD globulin is not useful for already sensitized, or RhD positive mothers; its administration could result in maternal blood being bound and taken out of circulation.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

Oxytocin activates phospholipase C to produce inositol 1,4,5-trisphosphate (IP3), which releases Ca2+ from intracellular stores. There are thought to be other mechanisms by which myometrium is stimulated by Oxytocin including increased sensitisation of the myometrium and increased calcium entry into cells. cAMP and Protein Kinase A inhibit myometrial contractility.

TORCH infections are responsible for perinatal complications. CMV is the most common amongst them. Primary infection often produces no symptoms or mild non-specific flu-like symptoms in the mother. The diagnosis is often made after abnormalities are seen in the foetus on ultrasound scan. The main features seen in an affected foetus are FGR, microcephaly, ventriculomegaly, ascites or hydrops. Some foetuses which are infected may not show any features on ultrasound, but may later be found to have neurological damage such as blindness, deafness or developmental delay. The neonate can also be anaemic and thrombocytopenic, with hepatosplenomegaly, jaundice and a purpureal rash.

Postpartum haemorrhage (PPH) is a cumulative blood loss greater than 1000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery.

The first step in managing hemorrhagic shock is recognition. This should occur before the development of hypotension. Close attention should be paid to physiological responses to low blood volume. Tachycardia, tachypnoea, and narrowing pulse pressure may be the initial signs.

Tachycardia is typically the first abnormal vital sign of hemorrhagic shock. As the body attempts to preserve oxygen delivery to the brain and heart, blood is shunted away from extremities and nonvital organs. This causes cold and modelled extremities with delayed capillary refill. This shunting ultimately leads to worsening acidosis.

Patient mentioned in the given case has developed clinical features of cervical insufficiency and the possible treatment options include:
1- Cerclage, which is the technique used for the reinforcement of cervical ring with nonabsorbable suture material and is indicated based on ultrasonographic findings. It is the treatment of choice when cervical shortening is detected by ultrasonography before 22 to 24 weeks of gestation.

2- Vaginal progesterone is used to reduce the risk of preterm delivery in women who have a prior history of idiopathic preterm delivery or cervical shortening, which is confirmed in the current pregnancy also by ultrasonography.This method is applicable only to those women who do not meet the criteria for Cerclage.

All the other options of management are incorrect in the given case.

Blood in the peritoneal cavity rarely causes rigidity like that of a board (this is generally only found when chemical or purulent peritonitis is present).

When there is blood, there is usually a lot of rebound soreness and a lot of guarding.

A tubal ectopic pregnancy causes discomfort and tenderness in the lower abdomen, but it is not always localised to the side of the disease.

Shock is uncommon since the diagnosis is usually recognised before there is enough blood loss to elicit such signs.

Pelvic soreness is more prevalent than a pelvic mass that may be seen on a clinical exam.
Where a mass is visible, it could be an ectopic pregnancy, but it’s more likely to be a pregnancy surrounded by a blood clot caused by a leaking ectopic pregnancy.

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.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.

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.

Misoprostol is not as effective as oxytocin but may be used if Oxytocin is not available e.g. home birth Recommended doses of Oxytocin For vaginal deliveries: 5 iu or 10 iu by intramuscular injection. For C-section: 5 iu by IV injection

Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. The uncontrolled leakage of urine into the vagina is the hallmark symptom of patients with UGFs. Patients may complain of urinary incontinence or an increase in vaginal discharge following pelvic surgery or pelvic radiotherapy with or without antecedent surgery. The drainage may be continuous; however, in the presence of a very small UGF, it may be intermittent. Increased postoperative abdominal, pelvic, or flank pain; prolonged ileus; and fever should alert the physician to possible urinoma or urine ascites and mandates expeditious evaluation. Recurrent cystitis or pyelonephritis, abnormal urinary stream, and haematuria also should initiate a workup for UGF.

Urinary trace infection presents with dysuria and urgency.
Detrusor instability causes urge incontinence.
Neurogenic bladder from diabetic neuropathy would also have urgency.

Polycystic kidney disease (PKD) can either be autosomal dominant or recessive. The autosomal dominant variant is more common in adult PKD however, the recessive pattern is more common in infantile PKD.

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.

Atenolol is considered teratogenic and has two main risks: fetal bradycardia and neonatal apnoea. ACE inhibitors and angiotensin II receptor blockers are also known to be teratogenic (even though large-scale studies are difficult to conduct during pregnancies).

Non-severe Hypertension and asymptomatic at ≥ 20w
(BP ≥ 140/90 and < 160/110mmHg)
• Urine dipstick analysis
• Quantify 24hr urine protein excretion/U-PCR
• Start Methyldopa 500mg 8hrly
• Do Hb, Platelet count, s-Cr, AST/ALT, Urine specimen for MC&S
• If gestational hypertension is diagnosed and BP is well controlled, continue antihypertensive therapy and plan delivery at 38 weeks if all remains well in the interim

Hypertension with symptoms or severe features
• Admit in High care unit and nurse in left lateral
• Insert urinary catheter and IV line
• Administer IV Ringers lactate (total volume of IV fluid administered should not exceed
80mls/hr)
• Start Magnesium Sulphate
• Control BP
• Perform an ultrasound (if indicated) or assess clinically to determine fetal viability,
EFW (Estimated Fetal Weight) and liquor volume and, if possible
• If GA ≥ 34/40 or EFW ≥ 2200g expedite delivery
• If GA ≥ 26/40 and < 34/40, administer course of steroids to enhance fetal lung maturity
• If patient is stabilised, offer expectant management if < 34 weeks and eligible

Acute severe hypertension (DBP ≥ 110mmHg and or SBP ≥ 160mmHg)
• Administer Nifedipine (Adalat®) 10mg per os immediately
• Start maintenance therapy with Nifedipine (Adalat XL®) 30-60mg BD orally (maximum
120mg/day)
• Aim for DBP ≤ 110 and SBP ≤ 160mmHg
• If BP is still high after 30 minutes, repeat Nifedipine (Adalat®) 10mg orally every 30
minutes, for a maximum of three dosages or until BP < 160/110mmHg (contraindication:
tachycardia > 120 bpm, unable to swallow, cardiac lesion).
• If after 30 minutes BP is still high then give Labetalol 20, 40, 80, 80 and
80mg (max 300mg) as bolus doses at 10 minute intervals, checking BP every 10
minutes until BP < 160/110mmHg. Contra-indications: patients with asthma and
ischaemic heart disease. If BP monitoring is not achievable at 10 minute intervals then
patient should be transferred to ICU for a Labetalol infusion.

Oxytocin binds to G-protein-coupled receptors and requires Magnesium and cholesterol for this process to occur.

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

Multiple studies have identified several risk factors for uterine atony such as polyhydramnios, fetal macrosomia, twin pregnancies, use of uterine inhibitors, history of uterine atony, multiparity, or prolonged labour.

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.

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

Micturition is defined as a process of expelling urine from the body. It is caused by the reflex contraction of detrusor muscle. Urinary bladder is a hollow muscular organ which can store 400-600ml of urine until it is expelled from the body. The first urge to urinate is felt when the bladder is filled with around 150ml of urine. The reflex action is initiated when the stretch receptors located in the bladder wall are stimulated. The afferent fibres pass to the pelvic splanchnic nerves to the 2nd, 3rd, and 4th sacral segments and some pass through the hypogastric plexus to the first and second lumbar segments of the spinal cord. Efferent pathways from the 2nd, 3rd, and 4th sacral segments leave the cords and through the splanchnic nerves and inferior hypogastric plexus supplies the smooth muscle of the bladder i.e. detrusor muscle. Detrusor muscle contracts and the sphincters are relaxed.

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

Extreme headache, vision defects, such as blurring of the eyes, rib pain, sudden swelling of the face, hands or feet are all consistent with pre-eclampsia. Women with the mentioned symptoms should have their blood pressure checked immediately. They should also be checked for proteinuria.

Diarrhoea is not related to pre-eclampsia. Pruritus would be more related to pregnancy cholestasis. Meanwhile, bruising and abnormal LFTs are common in complicated pre-eclampsia but not in an uncomplicated one.

Mefenamic acids is a NSAID. It works by inhibiting prostaglandin synthesis – It inhibits COX-1 and COX-2 hence reducing the process of inflammation. Activation of antithrombin III and inactivation of factor Xa is the primary mechanism of action of Heparin.

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 75g 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.

Pregnant maternal serum AFP levels elevated: Neural tube defects (e.g., spina bifida, anencephaly); Omphalocele; Gastroschisis.

Pregnant maternal serum AFP low levels: Down syndrome

Prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in preparation for the production of milk. However, milk is not secreted then, because progesterone and oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.

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.

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 bladder is supplied by branches of the internal iliac artery, including the superior vesical artery, branches of the gluteal and obturator arteries and the inferior vesical artery in males and the vaginal and the uterine arteries in females.

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.

Endocrine hormones are released from their site of origin and travel through the blood to act on other distant target organs. Autocrine hormones act within the same cell and exocrine glands secrete their products into ducts.

Tamoxifen is a SERM that is effective in treating hormone-responsive breast cancer, it acts as an antagonist to prevent receptor activation by endogenous oestrogen. As agonist of the endometrial receptors it promotes endometrial hyperplasia and hence increases the risk of endometrial cancer.

The most likely cause of her bleeding is an endometrial polyp formation due to the tamoxifen.

Tamoxifen is often prescribed to decrease risk of breast cancer recurrence in premenopausal women with oestrogen receptor-positive cancers.

As with any medication, it has known side effects, which include endometrial polyp formation, subendometrial oedema and, rarely, endometrial carcinoma.

A polyp or carcinoma can cause uterine bleeding, but a polyp is more likely to occur.

Routine endometrial thickness screening is not recommended in all women taking tamoxifen. However, in cases of abnormal bleeding, ultrasound assessment of endometrial thickness, hysteroscopy and curettage are indicated to assess the endometrium in more detail.

Tamoxifen is not associated with endometrial atrophy.

Endometrial metastasis from a breast cancer is rare, and tamoxifen would not usually induce follicular development in a woman who has had chemotherapy and resultant amenorrhoea.

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

Prothrombin time is increased in:
– Factor V deficiency
– Vitamin K deficiency (which affects factors 2,7 and 10)
– Warfarin therapy
– Severe liver failure
Protein C is an anticoagulant and deficiency results in a hyper-coagulable state with tendency towards thrombosis.

Cholesterol is the common precursor for progesterone and androgen production.

Klinefelter syndrome occurs in 1:1000 individuals. They are phenotypically male and genotypically they have 47,XXY chromosomes. These individuals have small testes, are tall with disproportionate long lower limbs.40% will also have gynecomastia.

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.

There are between 250 and 400 lobules in each testis. The lobule is a structural unit of the testis with each lobule contained in one of the intervals between fibrous septa which extend between the mediastinum testis and the tunica albuginea. Each lobule contains 1 to 3 seminiferous tubules.

First stage of the labour starts with the contractions of the uterus. With time, the no. of contractions, its duration and intensity increases. It ends once the cervix is fully dilated.

Diastolic murmurs should be considered pathological until proven otherwise. The following are common and typically benign findings in pregnancy: A third heart sound after mid-pregnancy. Systolic flow murmurs are common. Left axis deviation on ECG is common, Sagging ST segments and inversion or flattening of the T wave in lead III may also occur

Menstrual cycle can be divided into the follicular phase and luteal phase. In the luteal phase, there is an increase in progesterone secretion and LH levels are low. If the ova is fertilized, it is implanted in the endometrium. In case of failure in fertilization, there is gradual decrease in progesterone and LH levels.

The Rotterdam criteria for the diagnosis of PCOS is based on a score of two out of the three criteria:
1) Oligo or anovulation
2) Hyperandrogenism – clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
3) on ultrasound – contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 cm3 or greater.

Chlamydia is one of the most prevalent STIs in the UK. Many infected individuals can be asymptomatic making it difficult to detect. The gold standard in the diagnosis of Chlamydia is the nucleic acid amplification test (NAAT). A sample is taken from a vulvovaginal self swab, or a cervical swab on speculum examination in women.

In a person who is infected by streptococcus (Group B) should be started on benzylpenicillin as soon as possible. In case of allergy vancomycin should be started at 1g every 12 hours. Tetracyclines should be avoided in pregnancy.

Gestational trophoblastic disease (GTD) is a group of tumours defined by abnormal trophoblastic proliferation. Trophoblast cells produce human chorionic gonadotropin (hCG).

GTD is divided into hydatidiform moles (contain villi) and other trophoblastic neoplasms (lack villi). The non-molar or malignant forms of GTD are called gestational trophoblastic neoplasia (GTN).
Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. Risk factors include extremes of age, ethnicity, and a prior history of an HM which suggests a genetic basis for its aetiology.

GTD is best managed by an interprofessional team that includes nurses and pharmacists. Patients with molar pregnancies must be monitored for associated complications including hyperthyroidism, pre-eclampsia, and ovarian theca lutein cysts. Molar pregnancy induced hyperthyroidism should resolve with the evacuation of the uterus, but patients may require beta-adrenergic blocking agents before anaesthesia to reverse effects of thyroid storm. Pre-eclampsia also resolves quickly after the evacuation of the uterus. Theca lutein cysts will regress spontaneously with falling beta-HCG levels. However, patients must be counselled on signs and symptoms of ovarian torsion and ruptured ovarian cysts.

A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again.

Second-trimester ultrasound markers have low sensitivity and specificity for detecting Down syndrome, especially in a low-risk population.

The highest detection rate is acquired with ultrasound markers combined with gross anomalies. Although the detection rate with this combination of markers is high in a high-risk population (50 to 75 percent), false-positive rates are also high (22 percent for a 100 percent Down syndrome detection rate).

Endometriosis is a chronic gynaecologic disease characterized by the development and presence of histological elements like endometrial glands and stroma in anatomical positions and organs outside of the uterine cavity. The main clinical manifestations of the disease are chronic pelvic pain and impaired fertility. The localization of endometriosis lesions can vary, with the most commonly involved focus of the disease the ovaries followed by the posterior broad ligament, the anterior cul-de-sac, the posterior cul-de-sac, and the uterosacral ligament.

The clinical presentation of the disease differs in women and may be unexpected not only in the presentation but also in the duration. Clinicians usually suspect and are more likely to diagnose the disease in females presenting with the typical symptomatology such as dyspareunia, namely painful sexual intercourse, pelvic pain during menstruation (dysmenorrhea), pain in the urination (dysuria), defecation (dyschezia), and/or infertility. The pain is usually characterized as chronic, cyclic, and progressive (exacerbating over time). Furthermore, some women suffering from endometriosis experience hyperalgesia, a phenomenon, when even with the application of a nonpainful stimulus, an intolerable painful reaction is released. This condition indicates neuropathic pain.

Tenderness on vaginal examination, palpable nodules in the posterior fornix, adnexal masses, and immobility of the uterus are diagnostically indicating findings of endometriosis.

Complete abortion is defined as a ‘complete’ passage of all conception products.

The first day of the last menstrual period and findings on any prior ultrasounds should be determined to establish the gestational age and location of the pregnancy. An abdominal exam should be performed to assess for peritoneal signs that might indicate a ruptured ectopic pregnancy or extra-uterine extension of a septic abortion. Lastly, a pelvic exam is central to the evaluation of suspected miscarriage. It should include both speculum-facilitated visualization of the cervix and a bimanual examination to assess for cervical motion tenderness that may indicate a septic abortion or an adnexal mass that may herald ectopic pregnancy.

Early pregnancy loss takes many different forms. In missed abortion, there is asymptomatic or ‘missed’ death of the embryo or foetus without sufficient uterine contractions to push out the products of conception. In contrast, threatened abortion is characterized by symptomatic, ‘threatened’ expulsion of the products of conception, yet the cervical os remains closed, and the embryo or foetus remains viable.

Although there is a lack of consensus, complete abortion is often defined as the absence of a gestational sac on ultrasound with an endometrial stripe thickness of less than 30 mm.

Arcuate means ‘bow shaped’ and there are different arcuate lines in anatomical terms. Regarding the pelvic brim this is composed of the arcuate line of the ilium, pectineal line and prominences of sacrum and pubic symphysis (as demonstrated in the images below). As can be seen the arcuate line is a smooth rounded border on the internal surface of the ilium inferior to the iliac fossa and Iliacus. Image sourced from Wikipedia Note: The pelvic outlet is also called the inferior aperture. The pelvic brim is the superior aperture

An LSIL Pap test shows mild cellular changes. The risk of a high-grade cervical precancer or cancer after an LSIL Pap test is as high as 19 percent.

As with an ASC-US Pap test, an LSIL Pap test is evaluated differently depending upon age. For women ages 25 or older, follow-up depends upon the results of human papillomavirus (HPV) testing:

– Women who test positive for HPV or who have not been tested for HPV should have colposcopy.
– Women who test negative for HPV can be followed up with a Pap test and HPV test in one year.

All other options are not acceptable for the above mentioned reasons.

Lower abdominal pain during menstrual periods and lower back or leg pain are associated with endometriosis in the uterosacral ligaments. Endometriosis can cause diarrhoea and IBS type symptoms. Note Endometriosis on the uterosacral ligament can cause tender nodules to form. These can be palpated during pelvic exam. Tender nodules are specific to endometriosis of the uterosacral ligament so if the question mentions feeling a tender nodule during PV exam think endometriosis of the Uterosacral ligaments!

1. First-degree trauma corresponds to lacerations of the skin/vaginal epithelium alone.
2. Second-degree tears involve perineal muscles and therefore include episiotomies.
3. Third-degree extensions involve any part of the anal sphincter complex (external and internal sphincters):
i Less than 50 per cent of the external anal
sphincter is torn.
ii More than 50 per cent of the external anal
sphincter is torn.
iii Tear involves the internal anal sphincter
(usually there is complete disruption of the
external sphincter).
4. Fourth-degree tears involve injury to the anal sphincter complex extending into the rectal mucosa.

If a pregnant woman develops primary herpes simplex infection after 30 weeks gestation, her risk for transmission of herpes simplex virus to the neonate leading to neonatal infection increases significantly.
Below mentioned are the most common risk factors resulting in intrapartum herpes simplex infection of the baby:
– Premature labor
– Premature rupture of membrane
-Primary herpes simplex infection near the time of delivery
– Multiple lesions in the genital area
The most appropriate management for such case includes:
– Checking for herpes simplex infection with PCR testing (cervical swab)
– Prophylactic antiviral therapy of the mother from 36th week until delivery
– Cesarean section delivery

In the case above mentioned, it is better to start antiviral therapy immediately and consider cesarean section to minimize the risk of vertical transmission of infection to the neonate.

If the patient has a negative Chlamydia screen then a stat dose of metronidazole monotherapy is appropriate. You do not know this patients Chlamydia status and therefore dual therapy with metronidazole + doxycycline or azithromycin is appropriate.

The normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.

Vulva is defined by the area which is located outside the female vagina and comprises of the labia majora, labia minora, clitoris, mons pubis and Bartholin glands. It is supplied by the vestibula branch of pudental artery.
Inferior hemorrhoidal artery supplies the lower part of the rectum.
Femoral artery is the continuation of external iliac artery and supplies most of the leg.

During the early fetal life, oogonia proliferate by mitosis. They enlarge to form primary oocyte before birth. No primary oocyte is form after birth. The primary oocyte is dormant is the ovarian follicles until puberty. As the follicle matures, the primary oocyte completes its first meiotic division and gives rise to secondary oocyte. During ovulation the secondary oocytes starts the second meiotic division but is only completed if a sperm penetrates it. This 1st and 2nd meiotic division is known as ootidogenesis.

The ischial spines and palpable through the vagina and are used as landmarks to assess the decent of the fetal head from the cervix. It also serves as a landmark for giving the pudendal block.

Use of angiotensin II receptors blocks and ACE inhibitors are known to result in renal dysgenesis. Due to renal dysgenesis oligohydramnios occurs that leads to IUGR.

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.

This patient has a regular and long menstrual period. The most crucial thing in this case is to rule out anovulation.
Serum progesterone concentration is the best test for detecting ovulation.
Ovulation has occurred if the level is greater than 20nmol/L.
This test should be performed 3 to 10 days prior to the start of the next anticipated period.

Endometrial hyperplasia with atypia is at high risk of progression to cancer and hysterectomy is indicated There is high risk of progression to cancer with endometrial hyperplasia with atypia and hysterectomy is indicated. Although weight loss would be beneficial this shouldn’t delay surgical management.

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 ischial spine is the anatomical landmark for assessing the station of the fetal head and also placing pudendal nerve blocks. (the pudendal nerve runs posterior to the ischial spine). The ischial spine can be palpated approximately 8cm into the vagina, at 4 and 8 o’clock.

Screening for gestational diabetes should be offered and performed between 24-28 weeks. It should be noted PCOS alone does not make screening essential. It is advised for PCOS patients who are overweight or if not overweight but has other risk factors (age >40, personal history of gestational diabetes or family history of type II diabetes). Screening is via a 2-hour post 75 g oral glucose tolerance test.

The median umbilical ligament is the remnant of the Urachus.

Common Risk factors for Ovarian torsion are presence of an ovarian mass, women who are in their reproductive age and history of infertility treatment with ovulation induction.
Common clinical presentations include sudden onset of unilateral pelvic pain along with nausea & vomiting and presence of a palpable adnexal mass. An adnexal mass with absent Doppler flow to ovary can be noted in ultrasound.
Laparoscopy with detorsion, ovarian cystectomy and oophorectomy if necrosis or malignancy is found are the common treatment options.

Acute lower abdominal pain in a nonpregnant women can have various causes including pathologies of the gastrointestinal, gynecologic, or urologic systems due to the close proximity of these structures. All of these cases have classic presentations which help to characterize the disease process and thereby to differentiate the diagnosis.

In the given case, patient presents with right lower quadrant pain which is classic for ovarian torsion, occurring due to rotation of the ovary around the infundibulopelvic ligament, causing ovarian vessel occlusion.  Although ovarian torsion can occur in any women in their reproductive-age, is seen more commonly in those with a history of ovarian cysts (eg, hemorrhagic cyst) or masses (eg, mature cystic teratoma) because of the greater size and density of the ovary which makes it prone to rotation and subsequent torsion. Patients will initially have intermittent pain associated with activity, as in this patient, due to partial ovarian torsion, this initial pain resolves when the adnexa spontaneously untwists and blood flow returns. When this progresses to complete ovarian torsion, patients typically develop sudden-onset, severe, nonradiating pain due to persistent ischemia, which is often associated with nausea and vomiting.

Ovarian torsion can be clinically diagnosed, but a Doppler ultrasound is performed to evaluate ovarian blood flow and also to confirm the diagnosis. Surgical detorsion to prevent ovarian necrosis and cystectomy/oophorectomy are the usual treatment options.

Any association of urinary symptoms will help to establish a urologic cause of acute right lower quadrant pain like pyelonephritis, nephrolithiasis, etc.  However, patients with urologic conditions typically presents with suprapubic or flank pain which radiates to the right lower quadrant, making this diagnosis less likely in the given case.

A family history of malignancy usually does not aid in the diagnosis of acute lower abdominal pain. Although some ovarian cancers are inherited, patients with ovarian cancer typically have a chronic, indolent course with associated weight loss, early satiety, and abdominal distension.

Having multiple sexual partners is considered a risk factor for sexually transmitted infections and pelvic inflammatory disease, which can be a cause for lower abdominal pain. However, patients will typically have fever, constant and diffused pelvic pain along with rebound and guarding.

Recent sick contacts are a risk factor for gastroenteritis, which can present with nausea, vomiting and abdominal pain. However, in this case patient will typically have diffuse, cramping abdominal pain which will worsen gradually; along with persistent vomiting and diarrhea.

Ovarian torsion typically causes intermittent lower abdominal pain followed by sudden-onset of severe, nonradiating unilateral pain with associated nausea and vomiting. Ovarian torsion can occur in women in their reproductive-age, particularly those with a history of ovarian cysts.

AFP is a glycoprotein that is synthesized in the fetal liver (primarily), umbilical vesicles and the gut. It is found in elevated quantities in the fetal serum and peaks at around 14 week of gestation.

The juxtaglomerular apparatus is the main site for the production of renin. It plays an important role in the regulation of the blood pressure. These structures are mainly located in the cortex of the kidneys.

Postmenopausal haemorrhage has started in this patient. Menopause is defined as the permanent cessation of menstruation and fertility that occurs 12 months after the previous menstrual period.

Atrophic vaginitis caused by oestrogen insufficiency is the most likely reason for this woman’s postmenopausal haemorrhage. It can also induce vaginal dryness and soreness during sexual intercourse.

Endometrial hyperplasia is unlikely to develop without hormone replacement therapy or oestrogen stimulation of the endometrium.

Similarly, endometrial cancer is a less likely cause of this patient’s post-menopausal bleeding.

A year ago, this woman received a normal cervical screening test. Cervical cancer is extremely unlikely to occur. After 12 months of no oestrogen, it’s also unlikely that you’ll have any irregular periods.

Chorion villus sampling is an invasive procedure which aims to collect the rapidly dividing cells in the placenta. It is used for numerous reasons including detection of early pregnancy, viability of the foetus, singleton pregnancy, confirm gestation age and for prenatal diagnosis of the fetal chromosomal abnormalities including diagnosis of Down’s syndrome. However it hold a 2% chance of miscarriage during the procedure. Nuchal thickness and imaging are part of the combined test that must have been performed before.

Female infants are thought to be born with the total number of gametes they will posses in their lifetime. About 1 million healthy oocytes are present at birth. However, only about 300,000 of these oocytes survive to puberty, a number which continues to decline until all the oocytes are depleted triggering menopause.

This patient has got thrush or a fungal infection in the vaginal area. Candida infection is most likely based on the white discharge and itching. A vaginal clotrimazole antifungal treatment is required.

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.

Galactopoiesis and Lactogenesis are stimulated by Prolactin. Dopamine released under hypothalamic control inhibits Prolactin production. Note oestrogen and progesterone inhibit lactogenesis up until term.

After the release of the oocyte, the theca and the granulosa cells form the corpus luteum which undergoes extensive vascularization for continued steroidogenesis. Progesterone is secreted by the luteal cells and is synthesized from cholesterol. The luteal phase lasts for 14 days and if implantation does not occurs the corpus luteum starts to degenerate. As B-HCG produced by the implanted embryo maintains it and without it luteolysis occurs.

Absolute contraindications to OCs include breast cancer, history of deep venous thrombosis or pulmonary embolism, active liver disease, use of rifampicin, familial hyperlipidaemia, previous arterial thrombosis, and pregnancy, while relative contraindications include smoking, age over 35, hypertension, breastfeeding, and irregular spontaneous menstruation.

In this case, induction of labour at 37 weeks of gestation was necessary due to the absence of spontaneous of labour 24 hours after rupture of membranes. High doses of Syntocin and large volume of fluids may be required particularly when induction is done before term.

Syntocin infusion can lead to uterine hypertonus and tetany which can result in fetal distress at any dosage. This is a common reason to decrease or stop the infusion and an indication for Caesarean delivery due to fetal distress

Uterine rupture can occur as a result of Syntocin infusion especially when the accompanying fluids do not contain electrolytes, which puts the patient at risk for water intoxication.

Maternal hypotension results from Syntocin infusion, not hypertension.

Dermoid cysts and teratomas contain elements from multiple germ cell layers. They are often considered the same entity (even in medical texts) however a dermoid is composed only of dermal and epidermal elements. A teratoma has mesodermal and endodermal elements Mature teratomas are composed of well-differentiated derivations from at least 2/3 germ cell layers (i.e. ectoderm, mesoderm, and endoderm). They contain developmentally mature skin complete with hair follicles, sweat glands, sometimes hair, and sometimes sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue.

Prolactin levels rise steadily during pregnancy during which time it promotes mammary growth (along with the other hormones mentioned below). Oestrogen and progesterone inhibit lactogenesis and it is only with the loss of these placental steroid hormones at term that Prolactin exhibits its lactogenic effect.

Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis – Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis. This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage- Because the patient’s HBsAg is negative, she is not the source of her husband’s infection. Full treatment for this patient has an efficacy of only 75%, so follow-up testing is still needed.

HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.

The 1st stage of wound healing is haemostasis. Even in incised wounds a small haematoma forms. Here the clotting cascade is activated by tissue factor and endothelial cells resulting in activation of platelets. This results in platelet aggregation and the laying down of a fibrin mesh that is cross linked and holds the platelets in place.
Wound healing is typically divided into phases:
1. Haemostasis Phase
2. Inflammatory phase
3. Proliferation phase
4. Remodelling phase

Bicarbonate is the main buffer in blood.

Her most likely diagnosis would be an ovarian carcinoma. Any palpable adnexal mass in a post-menopausal woman is a red flag for an ovarian malignancy and should be assumed so until proven otherwise.

Endometrial cancer typically presents with a post-menopausal bleed and although there might be uterine enlargement, an adnexal mass is generally absent.

It is very rare for follicular cysts to develop following menopause and it is uncommon for post-menopausal women to have a benign ovarian tumour, which is more common in younger women. A degenerating leiomyoma would be unlikely in this case, especially since her pelvic examination three years ago was normal (no history of leiomyoma noted).

1 in 150 is the cut off. Where pre-natal screening shows a risk of 1 in 150 or greater invasive testing is typically offered.

of cases there is no permanent neurological disability. Shoulder dystocia is the most common cause of Erb’s palsy (Erb-Duchenne palsy) where there is injury to C5 and C6 of the brachial plexus (C5 to T1)

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.

Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.

Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia.

During the first 8 weeks of pregnancy, concentrations of hCG in the blood and urine usually double every 24 hours. Levels of the hormone typically peak at around 10 weeks, decline until 16 weeks, then remain constant.

This is stage 2B.

2010 FIGO classification of cervical carcinoma
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, Greater than 4 cm in greatest dimension 2 Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis
4A – Invades mucosa bladder and rectum
4B – Distant Metastasis

The two main cell types of the ovaries:
1. The theca cells produce androgen in the form of androstenedione. The theca cells are not able to convert androgen to oestradiol themselves. The produced androgen is therefore taken up by granulosa cells.
2. The neighbouring granulosa cells then convert the androgen into oestradiol under the enzymatic action of aromatase FSH induces the granulosa cells to produce aromatase for this purpose

These are features of excess growth hormone i.e. Acromegaly. Down’s and Cri du chat typically cause Micrognathia (small jaw)

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

Uterine blood flow increases 40-fold to approximately 700 mL/min at term. The uterus is 50–60 g with a volume of approximately 10ml prior to pregnancy and 1000 – 1200 g with a volume of 5000ml by term.

Trigeminal nerve has three divisions, the first is the ophthalmic division that does not originate from any of the pharyngeal arches, the second and third divisions, namely, the maxillary and the mandibular region develop from the first pharyngeal arch.
Pharyngeal Arches:
1st = Trigeminal V2 & V3 (CN V)
2nd = Facial (CN VII)
3rd = Glossopharyngeal (CN IX)
4th and 6th = Vagus (CN X)

Remember patients with PCOS have elevated LH. COCPs suppress synthesis and secretion of FSH and the mid-cycle surge of LH, thus inhibiting the development of ovarian follicles and ovulation COCPs reduce hyperandrogenism as reduced LH secretion results in decreased ovarian synthesis of androgens. Furthermore they stimulate the liver to produce Sex Hormone Binding Globulin which leads to decreased circulating free androgens. Other mechanisms include reduction in adrenal androgen secretion and inhibition of peripheral conversion of testosterone to dihydrotestosterone and binding of dihydrotestosterone to androgen receptors

Women with polycystic ovary syndrome (PCOS) have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed oestrogen that results from anovulation.

Additionally, secretory endometrium of some women with PCOS undergoing ovulation induction or receiving exogenous progestin exhibits progesterone resistance accompanied by dysregulation of gene expression controlling steroid action and cell proliferation.

Other risk factors include nulliparity, early menarche and late menopause, obesity and family history of endometrial cancer. Which rules out all the other options.

The maximum dose of lidocaine with adrenaline is 7mg/kg.

Dysplasia has 4 microscopic characteristics:
Anisocytosis (unequal cell size)
Poikilocytosis (abnormal cell shape)
Hyperchromatism (pigmentation)
Mitotic figures (increased cells currently dividing)

Hyperplasia and hypertrophy is characterised by increase in cell number and increase in cell size respectively, whereas atrophy means decrease in cell size.
Metaplasia is characterised by change of one form of cell to another type e.g. changes of columnar epithelium to squamous epithelium.

The Pudendal provides cutaneous innervation to the posterior external genitalia via one of its terminal branches called the perineal nerve (this further branches into the posterior labial nerves or posterior scrotal nerve in men). The ilioinguinal nerve provides anterior sensation via the anterior labial nerves (anterior scrotal nerve in men). The genital branch of the genitofemoral nerve contributes some fibres to the skin of the mons pubis and labia majora in females. The posterior cutaneous nerve of thigh sometimes overlaps sensory areas.

The risk of developing endometrial carcinoma is less than 5% over 20 years if the endometrium shows hyperplasia without atypia.
There are 2 types of Endometrial Hyperplasia:
1. Hyperplasia without atypia*
2. Atypical hyperplasia

Major Risk Factors:
Oestrogen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant)

Threatened miscarriage is a term used to describe any abnormal vaginal bleeding that occurs in first trimester, sometime associated with abdominal cramps. The cervix remains closed and the pregnancy may continue as normal.

Dizygotic means two (di) fertilized eggs (zygotes). Dizygotic twins occur when two eggs are fertilized by two separate sperm. Dizygotic twins are also known as fraternal or non-identical twins. They are the most common type of twins.

Unlike monozygotic twins (also known as identical twins), dizygotic twins do not share the same genes. Monozygotic twins share 100 percent of each other genes. Dizygotic twins share only 50 percent. This is the same genetic similarity found between siblings conceived and born at different times.

This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.

In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.

Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.

Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.

The pudendal nerve provides sensory and motor innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. The nerve gives the following branches in females: the inferior anal nerve, the perineal nerve and the dorsal nerve of the clitoris.

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

The case is most likely diagnosed a threatened miscarriage.
A diagnosis of threatened miscarriage is made when there is uterine bleeding in the presence of a closed cervix and is confirmed by the sonographic visualisation of an intrauterine pregnancy with detectable fetal cardiac activity. Miscarriages may not always follow even though there was multiple episodes or large amounts of bleeding, therefore the term “threatened” is used in these cases.
At 7 to 11 weeks of gestation, about 90 to 96 percent cases of pregnancies, will not usually miscarry if they have presented with an intact fetal cardiac activity along with vaginal bleeding and if bleeding occurs at the later weeks of gestational age chances of success rate is higher.

Topic review:
– Inevitable miscarriages presents with a dilated cervix, increasing uterine bleeding and painful uterine contractions. The gestational tissues can often be felt or seen through the cervical os and its passage occurs within a short time.
– In Incomplete miscarriage, the membranes will rupture passing the fetus out, but significant amounts of placental tissue will be retained. This occurs most commonly in late first trimester or early second trimester. On examination, the cervical os will be opened and the gestational tissue can be observed in the cervix, with a uterine size smaller than expected for gestational age, but not well contracted. The amount of bleeding varies but can be severe enough to cause hypovolemic shock. There will be painful cramps
ontractions and ultrasound reveals tissue in the uterus.
– A missed miscarriage refers to the in-utero death of the embryo or fetus prior to 20th week of gestation, with retention of the pregnancy for a prolonged period of time. In this case, women may notice that symptoms associated with early pregnancy like nausea, breast tenderness, etc have abated and they don’t “feel pregnant” anymore.
Vaginal bleeding may occur but the cervix usually remains closed. Ultrasound reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.
– Complete miscarriage, usually occurs before 12 weeks of gestation and the entire contents of the uterus will be expelled resulting in a complete miscarriage. In this case, physical examination reveals a small, well contracted uterus with an open or closed cervix with scanty vaginal bleeding and mild cramping. Ultrasound will reveal an empty uterus with no extra-uterine gestation.

Condition where there is insufficient fetal descent after pushing for ≥3 hours in nulliparous and ≥2 hours if multiparous women is defined as Second stage arrest of labor. Common risk factors for this presentation are maternal obesity, excessive weight gain during pregnancy and diabetes mellitus. Cephalopelvic disproportion, malposition, inadequate contractions and maternal exhaustion are the common etiologies of Second stage arrest of labor. Management includes Operative vaginal delivery or cesarean delivery as indicated in the case.

The second stage of labor begins with the dilatation of cervix to 10 cm and will end with fetal delivery. Parity and use of neuraxial anesthesia are the two factors which will affect the duration of second stage of labor and fetal station, which measures the descent of the fetal head through the pelvis determines its progression.

When there is no fetal descent after pushing for ≥3 hours or ≥2 hours in in nulliparous and multiparous patients respectively the condition is called an arrested second stage of labor. As her first delivery was a cesarean session due to breech presentation, this patient in the case is considered as nulliparous.

Most common cause of a protracted or arrested second stage is fetal malposition, which is the relation between the fetal presenting part to the maternal pelvis. Occiput anterior is the optimal fetal position as it facilitates the cardinal movements of labor, any deviations from this position like in occiput transverse position, can lead to cephalopelvic disproportion resulting in second stage arrest.
Inadequate contractions, that is less than 200 MVU averaged over 10 minutes, can lead to labor arrest but contractions are adequate in case of the patient mentioned.
Second stage arrest can be due to maternal obesity and excessive weight gain during pregnancy but this patient had a normal pre-pregnancy BMI of 20 kg/m2 and an appropriate weight gain of 15.9 kg 35 lb. So this also cannot be the reason.

Maternal expulsive efforts will change the fetal skull shape. This process called as molding helps to facilitate delivery by changing the fetal head into the shape of the pelvis. Whereas prolonged pressure on head can result in scalp edema which is called as caput, presence of both molding and caput suggest cephalopelvic disproportion, but is not suggestive of poor maternal effort.

Patients with a prior history of uterine myomectomy or cesarean delivery are at higher risk for uterine rupture.  In cases of uterine rupture, the patient will present with fetal heart rate abnormalities, sudden loss of fetal station (eg, going from +1 to −3 station) along with fetal retreat upward and into the abdominal cavity through the uterine scar due to decreased intrauterine pressure. In the given case patient’s fetal heart rate tracing is category 1 and fetal station has remained 0 which are non suggestive of uterine rupture.

When there is insufficient fetal descent after pushing ≥3 hours in nulliparous patients or ≥2 hours in multiparous patients is considered as second stage arrest of labor. The most common cause of second stage arrest is cephalopelvic disproportion, were the fetus presents in a nonocciput anterior position called as fetal malposition.

The pelvic floor or diaphragm is composed of Coccygeus and Levator Ani. Levitator Ani is composed of 3 muscles: puborectalis, pubococcygeus and iliococcygeal. Although Piriformis assists in closing the posterior pelvic outlet it is not considered a component of the pelvic floor

FEV1 and FVC are unchanged. FEV1/FVC ratio remains the same in pregnancy

This patient is towards the end of the first stage of labour and is having complications. Labour is divided into 3 stages. The first stage begins at regular uterine contractions and ends with complete cervical dilatation at 10 cm. It has a latent phase and an active phase- The active phase is usually considered to have begun when cervical dilatation reaches 4 cm. So this patient is in the active phase of the first stag- The second stage begins with complete cervical dilatation and ends with the delivery of the foetus. The third stage of labour is the period between the delivery of the foetus and the delivery of the placenta and fetal membranes.

This patient’s contractions seem adequate and yet the fetal heart tone with baseline 80/min and absent variability suggests fetal distress. This is category III of the fetal heart rate pattern because the baseline rate is < 110/min with absent variability. It is usually predictive of abnormal acid-base status. The recommended actions are maternal position change and oxygen administration, discontinuation of labour stimulus such as oxytocin, treatment of possible underlying conditions, and expedited delivery.
→ Magnesium sulphate infusion is mainly used to prevent eclamptic seizures and despite no evidence of its effectiveness as a tocolytic agent, it is used sometimes to reduce risks of preterm birth.
→ Fetal scalp pH monitoring would help determine if there is indeed an acidosis and should be done before deciding whether a Caesarean section is necessary, but maternal position change and oxygen administration should be done first.
→ Ultrasonography may be used for preinduction cervical length measurement or if the active stage has already started- It is considered more accurate than digital pelvic exam in the assessment of fetal descent; however, at this point maternal position change and oxygen administration should be done first.
→ Immediate Caesarean section would be done if fetal scalp pH monitoring revealed a pH < 7.20. At this point, the best next step is maternal position change and oxygen administration.

Transitional cell carcinoma of the bladder is most commonly caused by cigarette smoke. Other risk factors include naphthylamine, azodyes and long term cyclophosphamide use.

The arcuate line is a smooth rounded border on the internal surface of the ilium just inferior to the iliac fossa. It forms the boundary of the pelvic inlet.

There are different ways of monitoring fetal heart rate during pregnancy. It can be done by just auscultation or by electronic fetal heart rate monitoring which is done with the help of an ultrasound machine and has a low specificity but high sensitivity.

The female pelvic inlet tilts at an inclination that is about 60 degrees from the anatomical horizontal plane. This tilt is maintained by muscles and fascia. The pelvic outlet slopes at an angle of 15 degrees.

This patient has been unable to conceive for over a year, and her fallopian tubes are blocked. Her body mass index is 42.
Because she has obstructed Fallopian tubes, in-vitro fertilisation (IVF) is an alternative to getting pregnant for this patient.
A woman with a BMI over 35, on the other hand, will need twice as many IVF rounds to conceive as a woman of normal weight.
As a result, the greatest advise for successful IVF would be to decrease weight as the first step in management.
Obese (BMI less than 40) patients’ IVF success chances are reduced by 25% and 50%, respectively.

When face presentation is diagnosed, around 60% of cases are in the mentum anterior position, 25% are mentum posterior and 15% are mentum transverse; most malpositions rotate spontaneously into mentum anterior. A vaginal birth at term is possible only if the foetus is in the mentum anterior position.

From the 12th week of gestation the foetus starts yawning, sucking and swallowing.

GI Tract initially forms via gastrulation from the endoderm of the trilaminar embryo around week 3. It extends from the buccopharyngeal membrane to the cloacal membrane. Later in development there are contributions from all three germ cell layers.

The following cardiovascular changes occur during pregnancy:
– Blood volume slowly increases by 40-50%
– Heart rate rises by 15 beats/min above baseline
– Stroke volume increases by 25-30%
– Cardiac output increases by approximately 30-50%
– Systemic vascular resistance (SVR) decreases by 20-30%
– Diastolic blood pressure consequently decreases between 12 and 26 weeks but increases again to pre-pregnancy levels by 36 weeks.
As most of the changes occur in the first 12 weeks of gestation cardiac problems are likely to present in early pregnancy

CA-125 has found application as a tumour marker or biomarker that may be elevated in the blood of some patients with specific types of cancers, or other conditions that are benign. Increased level of CA125 appears in fifty percent of stage 1 ovarian cancer patients and more than 90% with stages 2-4 ovarian cancer. CA-125 is therefore a useful tool for detecting ovarian cancer after the onset of symptoms as well as monitoring response to treatment and for predicting a patient’s prognosis after treatment.

Management of PCOS includes OCP, cyclical oral progesterone, metformin, clomiphene (which is more effective in inducing ovulation than metformin) and life-style changes. In women who are tolerant to these therapies Gonadotrophins should be trialled. However lifestyle changes should be able to improve the condition significantly. Clomiphene shouldn’t be continued for more than 6 months.

During the ovulatory cycle, only one follicle will ovulate. The remaining non-ovulating follicles undergo disintegration. This process is known as atresia.

Ilioinguinal nerve injury is one of the most common nerve injuries associated with pelvic surgery.