Breast development occurs from the age of 9-13 at the onset of puberty. Delayed puberty is defined as the absence of breast development after the age of 13.

BP over 159/109 is classed as Severe. NICE guidance advises admission and treatment with oral Labetalol as 1st Line. Patient should have BP checked QDS and shouldn’t be discharged until BP is below 159/109

The changes seen in breast tissue with the menstrual cycle are accentuated during pregnancy. Deposition of fat around glandular tissue occurs, and the number of glandular ducts is increased by oestrogen, while progesterone and human placental lactogen (hPL) increase the number of gland alveoli. Prolactin is essential for the stimulation of milk secretion and during pregnancy prepares the alveoli for milk production. Although prolactin concentration increases throughout pregnancy, it does not then result in lactation since it is antagonized at an alveolar receptor level by oestrogen.

For this pregnant patient who recently travelled overseas most likely has a deep venous thrombosis (DVT). It would also be expected that the patient would have oedema in the symptomatic leg and account for the swelling described.

Though they could cause unilateral leg pain, neither symphyseal separation nor sciatica due to a prolapsed intervertebral disc usually occur as early as 18 weeks of gestation. This patient’s symptoms also do not suggest either diagnosis.

Pain due to trauma would usually be maximal at the site where the trauma took place, which would be in the knee for this patient. Traumatic pain and house cleaning also would not cause the pain described or result in ankle swelling.

The major constituents of breast milk are lactose, protein, fat and water. However, the composition of breast milk is not constant; early lactation differs from late lactation, one feed differs from the next, and the composition can even change
during a feed. Artificial infant formulas cannot therefore be identical to breast milk. In addition to IgA, breast milk contains small amounts of IgM and IgG and other factors such as lactoferrin, macrophages, complement and lysozymes

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.

Turner syndrome patients present with primary amenorrhea, have non functional or streak ovaries and cant conceive. They are 45X genetically.

Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. 

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

The best next step is to order an ultrasound of the pelvis to locate the IUCD in the uterine cavity.

Once the device is located, appropriate advice can be given about the pregnancy proceeding.

Uterine sounding and hysteroscopy are contraindicated in the presence of a viable pregnancy due to risks of infection and abortion.

Pelvic X-ray is indicated if the device cannot be located during the pelvic ultrasound. It can show if the device is in the peritoneal cavity or has been expelled from the uterus. It should only be done after the pregnancy.

In cases where the device is in the peritoneal cavity, a laparoscopy is indicated for device removal.

Pregnancy termination is not indicated simply because of the presence of an intrauterine device (IUCD) in the uterus, unless other factors dictate that this is appropriate.

Chickenpox or varicella is a contagious disease caused by the varicella-zoster virus (VZV). The virus is responsible for chickenpox (usually primary infection in non-immune hosts) and herpes zoster or shingles (following reactivation of latent infection). Chickenpox results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the chest, back, and face then spreads. It is accompanied by fever, fatigue, pharyngitis, and headaches which usually last five to seven days. Complications include pneumonia, brain inflammation, and bacterial skin infections. The disease is more severe in adults than in children.

Primary varicella infection during pregnancy can also affect the foetus, who may present later with chickenpox. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the foetus. Varicella infection in pregnant women could spread via the placenta and infect the foetus. If infection occurs during the first 28 weeks of pregnancy, congenital varicella syndrome may develop. Effects on the foetus can include underdeveloped toes and fingers, structural eye damage, neurological disorder, and anal and bladder malformation.

Prenatal diagnosis of fetal varicella can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised.

Antivirals are typically indicated in adults, including pregnant women because this group is more prone to complications.

Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.

In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.

Lymphatic drainage of the breast.
The lateral two thirds of the breast drains into the axillary lymph nodes. This constitute about 75% of the lymphatic drainage of the breast. The medial third of the breast drains into the parasternal lymph nodes and these communicate with the ipsilateral lymph nodes from the opposite breast. The superior part of the breast drains into the infraclavicular lymph nodes and inferior part drains into the diaphragmatic lymph nodes.

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.

Ladd’s bands are the most common form of peritoneal bands in malrotation of the intestine.

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.

The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.

Delayed puberty is defined as the absence of breast development in girls beyond the age of 13, and the absence of testicular development in boys beyond the age of 14. The incidence of delayed puberty is 3%, with the condition being more common in boys.

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.

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

Premenopausal women with asymptomatic simple cysts smaller than 8cm on sonograms in whom the CA125 value is within the reference range may be monitored, with a repeat ultrasonographic examination in 8-12 weeks.

Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts should be considered for surgical removal.

For this patient, a premenopausal woman, with an ovarian cyst size 8 cm x 12cm. Surgical management is indicated, hence referral to gynaecologist is appropriate.

Laparotomy or laparoscopic excision of cyst should be considered and performed by the gynaecologist not general practitioner.

Ovarian granulosa cells (GC) are the major source of oestradiol synthesis. Induced by the preovulatory luteinizing hormone (LH) surge, cells of the theca and, in particular, of the granulosa cell layer profoundly change their morphological, physiological, and molecular characteristics and form the progesterone-producing corpus luteum that is responsible for maintaining pregnancy. 

The median umbilical ligament is the remnant of the Urachus.

It is stage 2 of the disease.

Staging:
1 Confined to uterus
1A < 50% myometrial invasion
1B > 50% myometrial invasion
2 Cervical stromal invasion but not beyond uterus
3 Extension beyond the uterus
3A Tumour invades the serosa or adnexa
3B Vaginal and/or parametrial invasion
3C1 Pelvic nodal involvement
3C2 Para aortic nodal involvement
4 Distant Metastasis
4A Tumour invasion of the bladder and/or bowel mucosa
4B Distant metastases including abdominal metastases and/or inguinal lymph nodes

Fetal production of immunoglobulin begins early on at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth, through breast milk.

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.

Glucagon release is inhibited by increased blood glucose, ketones, free fatty
acids, insulin, raised urea levels and somatostatin. Glucagon is produced by alpha cells of the pancreas and increases the plasma glucose level by stimulating glycogenolysis and gluconeogenesis.

This patient is above 35 and smokes more than 15 cigarettes per day, which is an absolute contraindication to using a combined oral contraceptive pill. A BMI of greater than 35 is a relative contraindication to the usage of the combined oral contraceptive pill.
Progestogen-only contraception, such as etonogestrel implant, levonorgestrel intrauterine device, and depot medroxyprogesterone, should be offered to her.
Without initially attempting lifestyle changes, a referral for weight loss surgery is not required. Also, nicotine replacement therapy may aid in quitting smoking, but it may take time.

Adnexa refer to the anatomical area adjacent to the uterus, and contains the fallopian tube, ovary, and associated vessels, ligaments, and connective tissue. The reported incidence of adnexal masses in pregnancy ranges from 1 in 81 to 1 in 8000 pregnancies. Most of these adnexal masses are diagnosed incidentally at the time of dating or first trimester screening ultrasound (USS). Functional cyst is the most common adnexal mass in pregnancy, similar to the nonpregnant state. A corpus luteum persisting into the second trimester accounts for 13-17% of all cystic adnexal masses. Pain due to rupture, haemorrhage into the cyst, infection, venous congestion, or torsion may be of sudden onset or of a more chronic nature.

Paget’s disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. Symptoms may include redness of the nipple skin and crusting may occur around the area. In more advance cases, symptoms may include itching or a burning pain in the nipple.