The Mantoux test is based on type IV hypersensitivity reaction.

The pudendal nerve arises from the S2-S4 nerve roots and it lies medial to the internal pudendal artery while exiting the pelvis via the greater sciatic foramen. It curves around the sacrospinous ligament and re-enters the pelvis via the lesser sciatic foramen and from there it runs medial to the ischial tuberosity over the obturator internus in the pudendal canal to the deep perineal pouch.

Fetal Blood Sampling (FBS) should only be performed when the cervix is >3cm dilated.

Indications for FBS:
1. Pathological CTG in labour
2. Suspected acidosis in labour

Contraindications to FBS
– Maternal infection e.g. HIV, HSV and Hepatitis
– Known fetal coagulopathy
– Prematurity (< 34 weeks gestation)
– Acute fetal compromise

Interpretation of FBS results:
pH >7.25 = Normal -Repeat in 1 hour if CTG remains abnormal
7.21 to 7.24 = Borderline – Repeat in 30 minutes
<7.20 = Abnormal - Consider delivery

As B-HCG and TSH have similar structures, increased B-HCG can lead to hyperthyroidism, however there is only a 3% chance of this happening.

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

The female breast is made of about 15 to 20 individual lobes. The lobules each consists of alveoli which drain into a single lactiferous duct. The ductal system leads to lactiferous sinuses and collecting ducts which expel milk from openings in the nipple.

The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

A cervical screening test was performed on this patient, and the result revealed the presence of the Human Papilloma Virus Type non-16/18. Reflex liquid base cytology was conducted, but no further abnormalities were seen. In this case, the patient should be offered a 12-month repeat cervical screening cytology. If the patient’s repeated cervical screening cytology after 12 months revealed LSIL, she should be referred for a colposcopy.
If HPV is discovered at 12 months, regardless of the LBC result, some women may be at higher risk of having high-grade abnormalities and should be referred to colposcopy. These include:
– women 2 or more years overdue for screening at the time of the initial screen
– women who identify as being of Aboriginal or Torres Strait Islander
– women aged 50 years or older.

Summary of recommended actions based on the level of risk
Intermediate danger:
– HPV non-16/18 positive, intermediate risk (with negative or low-grade cytology)
If feasible, repeat the HPV test after 12 months.
A three-to-six-month delay would be acceptable. Delays of longer than six months are discouraged.
Follow up HPV test – HPV non 16/18 (possible high grade cytology or high-grade squamous lesion (HSIL) – Treated as Higher risk.

High-risk:
HPV non-16/18 positive on follow-up HPV test (with negative or low-grade cytology)
Refer to an expert right away for further investigation.

If your patient is: 2 years or more past due for screening at the time of the initial screening, and identifies as Aboriginal or Torres Strait Islander aged 50 or older, they may be at higher risk and should be referred to a professional at once for additional evaluation.

HPV 16/18 positive with any of the following non–16/18 positive: a glandular anomaly in high-grade cytology high-grade squamous lesion (HSIL) cancer. Refer to an expert right away for further investigation.

Currently, several colposcopy facilities are experiencing strong demand and extended wait times. If you are concerned that your patient will be delayed, you should call the specialist or clinic to which your patient has been referred.
On the Cure Test Pathway, wherever possible, continue testing as planned. A woman who has been treated for HSIL (CIN2/3) should have a 12-month follow-up co-test and annual tests after that. She can resume standard 5-yearly screening after receiving two consecutive negative co-tests.

Calcium phosphate salts are the most abundant form of calcium in the body, making up 99%. The majority of these salts are stored in the skeleton in different forms, mostly, hydroxyapatite, a lattice-like crystal composed of calcium, phosphates and hydroxide. The remaining calcium can be found in the extracellular fluid, tissues and skeletal muscle.

Parvovirus B19 is a single-stranded DNA virus, which is the causative organism for erythema infectiosum, also known as fifth disease or slapped cheek syndrome.

Maternal infection with parvovirus B19 is almost always associated with an increased risk of transplacental fetal infection throughout the pregnancy. Fetal infection results in fetal parvovirus syndrome, which is characterized by anemia­ hydrops with cardiac failure and possibly death.
The earlier the exposure occurs, it is more likely to result in fetal parvovirus syndrome and stillbirth is the common outcome in case of third trimester infection.

Women who have been exposed to parvovirus in early pregnancy should be informed on the possible risk of fetal infection and also should be screened for parvovirus B19 specific lgG.
– If parvovirus specific lgG is positive reassure that pregnancy is not at risk
– If parvovirus specific lgG is negative, serology for lgM should be performed
After infection with parvovirus, patient’s lgM is expected to become positive within 1 to 3 weeks and it will remain high for about 8-12 weeks. lgG levels will start to rise within 2 to 4 weeks after the infection.

This woman has a negative lgG titer which indicates that she is not immune to the infection. Although her lgM titer is negative now, this does not exclude the chance of infection as it takes approximately 1 to 3 weeks after infection for lgM to become positive, and will then remain high for 8 to 12 weeks. In such cases, it is recommended the serologic tests be repeated in 2 weeks when the lgM may become positive while lgG starts to rise.

– Positive lgM titers confirm maternal parvovirus infection. If that is the case, the next step would be fetal monitoring with ultrasound for development of hydrops at 1-2 weeks intervals for the next 6-12 weeks(needs referral). Once the fetus is found to have hydrops, fetal umbilical cord sampling and intrauterine blood transfusion are considered the treatment options.
– Positive lgG and negative lgM indicates maternal immunity to parvovirus.

Interpretation of serologic tests results and the further actions recommended are as follows:

If both IgM and IgG are negative, it means mother is not immune to parvovirus B19 infection, and an infection is possible. Further action will be Repetition of serological tests in 2 weeks.

If IgM is positive and IgG is negative, it means the infection is established. Fetal monitoring with ultrasound at 1- to 2-week intervals for the next 6- 12 weeks must be done.

If both IgM and IgG are positive, it means infection is established, and an infection is possible. Further action will be fetal monitoring with ultrasound at 1- to 2-week intervals for the next 6- 12 weeks.

If IgM is negative and IgG is positive, it means the mother is immune to parvovirus infection. In this case it is important to reassure the mother that the baby is safe.

Ventilation begins to increase significantly at around 8 weeks of gestation, most likely in response to progesterone-related sensitization of the respiratory centre to carbon dioxide and the increased metabolic rate. Significant alterations occur in the mechanical aspects of ventilation during pregnancy. Minute ventilation (or the amount of air moved in and out of the lungs in 1 minute) is the product of tidal volume and respiratory rate and increases by approximately 30–50 per cent with pregnancy. The increase is primarily a result of tidal volume, which increases by 40 per cent (from 500 to 700 mL), because the respiratory rate remains unchanged. The increase in minute ventilation is perceived by the pregnant woman as shortness of breath, which affects 60–70 per cent of women. This physiological dyspnoea is usually mild and affects 50 per cent of women before 20 weeks gestation, but resolves immediately postpartum.

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.

Skin signs during pregnancy may include: dark spots on the breasts, nipples and inner thighs, melasma (chloasma), linea nigra, stretch marks, acne, spider telangiectasis and varicose veins.

CVS has decreased in frequency with the recent increased uptake of cell-free DNA screening. It remains the only diagnostic test available in the first trimester and allows for diagnostic analyses, including fluorescence in situ hybridization (FISH), karyotype, microarray, molecular testing, and gene sequencing. CVS is performed between 10 and 14 weeks’ gestation. CVS has been performed before 9 weeks in the past, though this has shown to increase the risk of limb deformities and, therefore, is no longer recommended.

Most of the cases of down syndrome occur due to non disjunction trisomy 21 which is associated with increased maternal age. The non disjunction occurs in the maternal gametes.

Blood enters the right atrium of the fetal heart and most passes through the foramen ovale into the left atrium. From there it is pumped through the aorta. The foramen ovale is the major structure for bypassing the fetal pulmonary circulation. Some of the blood in the right atrium does enters the right ventricle and then into the pulmonary artery however most of this passes through the ductus arteriosus into the aorta thus bypassing the fetal pulmonary circulation.

The best time to perform amniocentesis is at the gestational age of 15 weeks or more. There is increased risk of abortion, respiratory problems and fetal talipes if amniocentesis is performed before the gestational age of 14 weeks.

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

In an ECG the P wave represents atrial depolarization. The QRS complex represents the ventricular depolarization, T waves represent ventricular repolarization and the U wave represents repolarization of the interventricular septum.