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.

Promethazine or Cyclizine are 1st choice options for management of nausea and vomiting in pregnancy according to NICE. Prochlorperazine is also appropriate 1st line.

Ovulation in the menstrual cycle usually occurs over 4 days. There is an increase in basal body temperature at the time of ovulation due to the effect of progesterone.

A high Day 21 progesterone level indicates ovulation and the release of an egg.

Dysmenorrhea is described as painful menstruation. The symptoms start at the time of ovulation and persist till menstruation.

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.

Twin gestations are generally at increased risk of complications and this risk is further stratified based on the chorionicity ie. number of placentas and amnionicity, the number of amniotic sacs of the gestation. In the given case patient has monochorionic diamniotic twins, which means 1 placenta and 2 amniotic sacs, based on the presence of 2 embryos, a single placenta and a thin intertwin membrane composed of 2 amniotic sacs that meets the placenta at a 90-degree angle (“T sign”). In patients who appear to have a single placenta, the base shape of the intertwin membrane distinguishes between a monochorionic (“T sign”) and fused dichorionic (“lambda sign”) gestation.
Monochorionic twins are at high risk for twin-twin transfusion syndrome (TTTS), which is a complication that can result in heart failure and fetal
eonatal mortality in both twins. In TTTS, unbalanced arteriovenous anastomoses are present between the shared placental vessels that supply the twins, because of these anastomoses, blood from the placental arteries from one twin (donor), which is of high resistance/pressure, is shunted into the placental veins of the other twin (recipient) with low resistance/pressure. This shunting of blood away from the donor twin causes anemia that leads to renal failure, oligohydramnios, low-output heart failure, and fetal growth restriction. In contrast, the shunting of blood toward the recipient twin causes polycythemia, which leads to polyhydramnios, cardiomegaly, high-output heart failure and hydrops fetalis. This in turn makes both twins at high risk for intrauterine and neonatal death.
Mild TTTS is expectantly managed with serial ultrasounds to evaluate for worsening clinical features, whereas moderate-to-severe cases are treated with laser coagulation of the placental anastomoses.

In monozygotic twins, placentation type is determined by timing of the twinning.  Twinning that occurs shortly after fertilization yields a dichorionic diamniotic gestation.  In contrast, the incomplete division (ie, fission) that can lead to conjoined twins occurs later in development and yields a monochorionic monoamniotic gestation. As the twins are in the same sac, monochorionic monoamniotic gestations can be complicated by cord entanglement but not possible in the given case as this patient has diamniotic twins.

Risk factors for placenta accreta, implantation of the placenta directly into the myometrium, include placenta previa and prior uterine surgeries like cesarean delivery, myomectomy, etc

Twin pregnancies are at increased risk of placenta previa (placental tissue that covers the internal cervical os); however, this patient has a fundal placenta, making this complication unlikely.

Monochorionic twin gestations can be complicated by twin-twin transfusion syndrome, which is potentially a fatal condition that results from unbalanced vascular anastomoses between the vessels supplying umbilical cords of each twin.

This patient presenting with oligohydramnios in her third trimester and had reported an episode of sudden gush of fluid secondary to ruptured membrane which she had mistaken to be “urinary incontinence”.  Hence, the most likely cause of oligohydramnios in this patient will be premature preterm rupture of membrane (PPROM).

An amniotic fluid volume which is less than expected for gestational age is called as Oligohydramnios and is typically diagnosed by ultrasound examination. This condition can be qualitatively described as reduced amniotic fluid volume and quantitatively as amniotic fluid index ≤5 cm or a single deepest pocket <2 cm. Oligohydramnios either can be idiopathic or may have a maternal, fetal or placental cause. Fetal prognosis in this case depends on several factors like the underlying cause, the severity of loss ie. reduced versus no amniotic fluid state and the gestational age at which oligohydramnios occurred. As an adequate volume of amniotic fluid is critical for the normal fetal movements, for fetal lung development and for cushioning the fetus and umbilical cord from uterine compression, so pregnancies complicated with oligohydramnios are at higher risk for fetal deformation, pulmonary hypoplasia and umbilical cord compression.
Oligohydramnios is also associated with an increased risk for fetal or neonatal death, which can either be related to the underlying cause of reduction in amniotic fluid volume or due to the sequelae caused due to reduced amniotic fluid volume. The amniotic fluid volume reflects the balance between fluid production and movement of fluid out of the amniotic sac and the most common mechanisms behind oligohydramnios are fetal oliguria/anuria or fluid loss due to rupture of membranes; also reduction in the amount of lung fluid or increased swallowing do not play major roles in this. Idiopathic cases as in idiopathic oligohydramnios, may be due to alterations in the expression of water pores like aquaporin 1 and aquaporin 3, present in fetal membranes and placenta.

Causes of oligohydramnios
a) Maternal causes includes:
– Medical or obstetric conditions associated with uteroplacental insufficiency like preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia.
– Intake of medications like angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab.
b) Placental causes are:
– Abruption of placenta
– Twin polyhydramnios-oligohydramnios sequence which is the Twin to twin transfusion
– Placental thrombosis or infarction
c) Fetal cases leading to oligohydramnios are:
– Chromosomal abnormalities
– Congenital abnormalities which are associated with impaired urine production
– Growth restriction
– Demise
– Post-term pregnancy
– Ruptured fetal membranes
– Infections
– Idiopathic causes

During First trimester: Etiology of oligohydramnios during the first trimester is often unclear. As the gestational sac fluid is primarily derived from the fetal surface of the placenta via transamniotic flow from the maternal compartment and secretions from the surface of the body of the embryo reduced amniotic fluid prior to 10 weeks of gestation is rare.

During Second trimester: Fetal urine begins to enter the amniotic sac and fetus begins to swallow amniotic fluid by the beginning of second trimester, therefore, during this period any disorders related to the renal/urinary system of the fetus begins to play a prominent role in the etiology of oligohydramnios. Some of such anomalies include intrinsic renal disorders like cystic renal disease and obstructive lesions of the lower urinary tract like posterior urethral valves or urethral atresia. Other common causes of oligohydramnios in the second trimester are maternal and placental factors and traumatic or nontraumatic rupture of the fetal membranes.

During Third trimester: Oligohydramnios which is first diagnosed in the third trimester is often associated with PPROM or with conditions such as preeclampsia or other maternal vascular diseases leading to uteroplacental insufficiency. Oligohydramnios frequently accompanies fetal growth restriction as a result of uteroplacental insufficiency.

This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day.  Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.

All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.

In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.

Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.

In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.

Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point).  This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.

Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.

Ovarian cancer is a gynaecological cancer that commonly affects women over 40 years. Risk factors for ovarian cancer include: infertility, a family history of ovarian, breast or colorectal cancer. There are some protective factors, which include: high parity and breastfeeding, early age at menarche and late age at menopause, and combined oral contraceptives, and statins.

Preeclampsia prevention
Preeclampsia is defined as a new-onset hypertension along with other features like proteinuria &/or end-organ damage at >20 weeks of gestation.
Patients with the following histories are at high risk for preeclampsia:
– Those with prior history of preeclampsia
– Those with chronic kidney disease
– Those with chronic hypertension
– Those with diabetes mellitus
– Multiple gestation
– Autoimmune disease
Patients belonging in the following criteria are at moderate risk for preeclampsia:
– Obesity
– Advanced maternal age
– Nulliparity

Preeclampsia is considered as the leading cause for maternal and fetal morbidity and mortality. This is due to its increased risk for complications such as stroke, placental abruption and disseminated intravascular coagulation. It is most likely caused due to abnormal vasoconstriction and increased platelet aggregation, which thereby results in placental infarction and ischemia. The condition can be effectively prevented by the administration of low-doses of aspirin at 12 weeks of gestation.

Patients with predisposing factors, such as chronic kidney disease, chronic hypertension and a history of preeclampsia, particularly with severe features or at <37 weeks gestation as in this patient, are at higher risk for developing preeclampsia.
In high risk patients, the only therapy proven to decrease the risk of preeclampsia is a daily administration of low-dose aspirin, as it inhibits platelet aggregation and helps in preventing placental ischemia. Treatment is initiated at 12 – 28 weeks of gestation, optimally before 16 weeks and is continued till delivery.

Betamethasone is a drug used to accelerate fetal lung maturity in patients who are prone to imminent risk of preterm delivery before 37 weeks of gestation. In this case, if the patient develops pre-eclampsia requiring an urgent preterm delivery betamethasone will be indicated.

High-doses (4 mg) of folic acid is indicated in patients with high risk for a fetus with neural tube defects, as in those who have a history of any prior pregnancies affected or those patients who use any folate antagonist medications. In the given case patient is at average risk and requires only a regular dose of 0.4 mg which is found in most prenatal vitamins.

Intramuscular hydroxyprogesterone is indicated in pregnant patients with prior spontaneous preterm delivery due to preterm prelabor rupture of membranes, preterm labor, etc to decrease the possible risk for any recurrence. In patients who underwent preterm delivery due to other indications like preeclampsia with severe features, fetal growth restriction, etc it is not indicated.

Vaginal progesterone is administered to decrease the risk of preterm delivery in patients diagnosed with a shortened cervix, which is usually identified incidentally on anatomy ultrasound scan done between 16 and 24 weeks of gestation. This patient is currently at her 14 weeks, so this is not advisable.

Patients at high risk for pre-eclampsia, like those with preeclampsia in a prior pregnancy, are advised to start taking a daily low-dose aspirin as prophylaxis for prevention of pre-eclampsia during pregnancy.

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

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.

Endometriosis is found in about one-third of women undergoing laparoscopy for chronic pelvic pain. Published studies show a diagnostic delay of 8.5 years from onset of symptoms to the eventual diagnosis of endometriosis!

This means that women can suffer for 8.5 years before a diagnosis of endometriosis is made, and appropriate interventions are carried out.

All other options are true statements about endometriosis.

The case presented points to a diagnosis of an autoimmune thyroiditis leading to hypothyroidism. The most common form of autoimmune hypothyroidism, Hashimoto’s, often presents with a goitre, positive for antibody tests against thyroid components i.e. anti-TPO and anti-thyroglobulin. Graves disease and toxic diffuse goitre are more likely to cause hyperthyroidism. While De-Quervain’s and endemic goitre may cause hypothyroidism, they don’t result in positive antibody tests.

Ulipristal is a progesterone receptor modulator that is used up to 120 hours following unprotected intercourse. It inhibits ovulation. The dose is 30 mg.

Most carcinomas spread primarily via lymphatic invasion. Renal cell is the exception spreading via the bloodstream.

CA-125 is the tumour marker specific for ovarian carcinoma.

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

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.

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.

Group B Streptococcus (GBS) or Streptococcus agalactiae is a Gram-positive bacteria which colonizes the gastrointestinal and genitourinary tract. In the United States of America, GBS is known to be the most common infectious cause of morbidity and mortality in neonates. GBS is known to cause both early onset and late onset infections in neonates, but current interventions are only effective in the prevention of early-onset disease.

The main risk factor for early-onset GBS infection is colonization of the maternal genital tract with Group B Streptococcus during labour. GBS is a normal flora of the gastrointestinal (GI) tract, which is thought to be the main source for maternal colonization.

The principal route of neonatal early onset GBS infection is vertical transmission from colonized mothers during passage through the vagina during labour and delivery.

Intravenous penicillin G is the treatment of choice for intrapartum antibiotic prophylaxis against Group B Streptococcus.

Monitoring after treatment for HSIL includes:
– colposcopy and cervical cytology at 4 to 6 months followed by HPV typing at 12 months and annually until a negative test is obtained on 2 subsequent check ups.
-2 yearly screening interval can be done afterwards.

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

Opiates and spinal anaesthetics reduce the variability of a CTG. Including some antihypertensives like labetalol and alpha methyl dopa.

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimetres from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimetres.

A fundal height that measures smaller or larger than expected — or increases more or less quickly than expected — could indicate:
– Slow fetal growth (intrauterine growth restriction)
– A multiple pregnancy
– A significantly larger than average baby (fetal macrosomia)
– Too little amniotic fluid (oligohydramnios)
– Too much amniotic fluid (polyhydramnios).

Bacterial vaginosis is a common infection of the vagina caused by the overgrowth of atypical bacteria, most commonly Gardnerella vaginalis, a gram indeterminate bacteria, which is also a facultative anaerobe. Patients often complain of foul-smelling fishy discharge and dysuria. In diagnosing BV, a swab is taken for microscopy, often revealing clue cells. Of the other organisms listed in the options, Neisseria is an obligate anaerobe, while Chlamydia trachomatis is an obligate intracellular aerobe. Treponema Pallidum is an aerophilic bacteria and Mycoplasma hominis is a pleomorphic parasitic bacterium.

Sinciput means the head is neither flexed nor extended. It is the area between forehead and crown and in this case the anterior fontanel is the presenting part.

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.

When the red cells are coated with immune IgG antibody, the cells do not agglutinate but when anti-IgG antiserum is added to these sensitized cells visible agglutination occurs. This is known as a positive direct coombs test.

Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.

Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.

Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.

3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.

Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.

Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.

The patient is presenting with classic symptoms of round ligament pain.
Round ligaments are structures which extends from the lateral portion of the uterus below to the oviduct and will travel downward in a fold of peritoneum to the inguinal canal to get inserted in the upper portion of the labium majus. As the gravid uterus grows out of pelvis during pregnancy, these ligaments will stretch, mostly during sudden movements, resulting in a sharp pain. Due to dextrorotation of uterus, which occurs commonly in pregnancy, the round ligament pain is experienced more frequently over the right side. Usually this pain improves by avoiding sudden movements, by rising and sitting down gradually, by the application of local heat and by using analgesics.

As the patient is not experiencing any symptoms like fever or anorexia a diagnosis of appendicitis is not likely. Also in pregnant women appendicitis often presents as pain located much higher than the groin area as the growing gravid uterus pushes the appendix out of pelvis.

As the pain is localized to only one side of groin and is alleviated with a heating pad the diagnosis of preterm labor is unlikely. In addition, the pain would persist even at rest and not with just movement in case of labor.

As the patient has not reported of any urinary symptoms diagnosis of urinary tract infection is unlikely.

Kidney stones usually presents with pain in the back and not lower in the groin. In addition, with a kidney stone the pain would occur not only with movement, but would persist at rest as well. So a diagnosis of kidney stone is unlikely in this case.