During follicular phase, there is an increase in gonadotrophin hormones and a proliferation of the endometrium occurs. The duration of the cycle depends upon the overall length of the menstrual cycle. The progesterone levels are increased in the luteal phase and not in follicular phase.

Clavulanic acid is a beta-lactamase inhibitor that is most often combined with a penicillin to form Augmentin or Co-amoxiclav for greater antibiotic efficacy. The drug works by irreversibly binding to enzymes present in bacteria which posses the Beta-lactamase enzyme. This enzyme is responsible for inactivating Beta-Lactam antibiotics such as penicillin.

This woman has signs and symptoms suggestive of cervical insufficiency, whose clinical features include pelvic pressure, premenstrual-like cramping and backache with increased vaginal discharge. Usually these symptoms will persist for several days to weeks.
Cervical insufficiency is seen between 14 – 20 weeks of gestation, which is presented as soft effaced cervix, with minimal dilation on physical examination and a 4 cm dilated and more than 80% effaced cervix will be the clinical presentation in a more advanced case.

Placental abruption presents with painful vaginal bleeding, whereas Placenta Previa presents as painless vaginal bleeding. Both cases will lead to shock but will not show any features of cervical insufficiency.

Anaemia, polyhydramnios, large for gestational age uterus and severe hyperemesis gravidarum are the commonly associated symptoms of a twin pregnancies.

New menstrual cycle after an abortion is expected to be presented with cervical dilation however signs of effacement will not be present along with it.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a non-stress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

Mirena coil is used for contraception and for long term birth control. It causes stoppage of menstrual bleeding however, in a few cases there may be inter-menstrual spotting.

This is a grade 1 prolapse

Uncontrolled endometrial proliferation due to excess and unregulated estrogen is the reason for intermenstrual bleeding and irregular menses along with abnormal uterine bleeding (AUB) in this patient. The condition is mostly associated with an increased risk of endometrial hyperplasia
ancer.
The absolute risk of endometrial hyperplasia
ancer is very low in women aged <45, therefore they can be started on combination medication with estrogen/progestin contraception (ie, medical management) without the evaluation of endometrium.  The estrogen component of medication regulates the menstrual cycle by build up the endometrium; whereas the progestin component helps in shedding of the endometrium.
However, patients who have continued irregular menstrual bleeding even while on combination contraceptives require further evaluation as they have failed to improve with medical management. In such patients, the endometrial lining will be too thick for the progestin to completely shed during menstruation and this unshed endometrium continues to undergo dysregulated proliferation, leading to an increased risk of endometrial hyperplasia
ancer. Therefore, patients age below 45 with AUB who have failed medical management require an endometrial biopsy.
AUB persistent above 6 months, obesity, and/or tamoxifen therapy are the other indications for endometrial biopsy in women age <45, as all of these will increase the amount of unopposed endometrial estrogen exposure. In patients with heavy menstrual bleeding and anemia, coagulation studies are performed to evaluate for bleeding disorders like von Willebrand disease. It is not necessary in this patient as she have a normal hemoglobin level. In patients with heavy, but regular (ovulatory) bleeding an endometrial ablation, which is a procedure used to remove the excess endometrium, can be considered as the treatment option. Endometrial ablation is contraindicated in undiagnosed cases of AUB as it prevents evaluation of the endometrium in patients with possible endometrial hyperplasia
ancer.

To check for abnormalities of the uterus like didelphys or of the Fallopian tube like scarring, a hysterosalpingogram is used but it is not useful to evaluate AUB. In addition, as the procedure could spread cancerous endometrial cells into the abdominal cavity, hysterosalpingogram is contraindicated in cases of undiagnosed AUB.

To evaluate secondary amenorrhea, ie. absence of menses for >6 months in a patient with previously irregular menses, a progesterone withdrawal test is used to determine whether amenorrhea is from low estrogen level, in negative cases there will be no bleeding after progesterone. This test is not indicated or relevant in this case as patient had continued bleeding while on oral contraceptives suggestive of high estrogen levels.

Evaluation for endometrial hyperplasia
ancer with an endometrial biopsy is required for those women age <45 with abnormal uterine bleeding who have failed medical management with oral contraceptives.

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.

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.

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.

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.

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

Factors shown to decrease risk of ovarian cancer are:
– Oral contraceptive use
– Higher Parity
– Breast feeding
– Hysterectomy
– Tubal Ligation
– Statins
– SLE

The management of low-grade squamous intraepithelial lesions (LSIL) on cervical cytology in women ages 25 years or older depends upon whether the patient underwent high-risk human papillomavirus (HPV) testing.

Women in this age group comprise two different populations in terms of cervical cancer screening strategies. Professional organizations recommend that women ages 25 to 29 years be screened with cytology alone, while women 30 years or older should be screened with cytology and HPV co-testing. Thus, the American Society for Colposcopy and Cervical Pathology (ASCCP) prefers that women ages 25 to 29 years are not managed based upon HPV results, even if an HPV test was performed at the time of screening. For women with ages 30 years or older and HPV positive, colposcopy must be performed.

Lower abdominal pain can be caused by any of the conditions listed in the answers.
A urinary tract infection is the most likely cause.
Unless it was an abdominal ectopic or an interstitial pregnancy, an ectopic pregnancy.
will almost definitely have shown up before the 15th week of pregnancy.
A retroverted gravid uterus may impinge at 15 weeks of pregnancy, however, this is unlikely to be linked to a temperature of 37.8°C.
It’s also possible that it’s the source of acute urine retention.
Complications of the corpus luteum cyst normally manifest themselves considerably earlier in pregnancy, and severe appendicitis is far less likely to be the source of discomfort than a urinary tract infection.

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.

Between 18-20 weeks of gestation is the best time to perform an ultrasound for the identification of any physical or anatomical abnormalities including neural tube defects.

Maternal serum screening for Down syndrome is best performed between 15-17 weeks of pregnancy and this screening includes analysis of alpha fetoprotein, estriol, and beta-HCG in maternal blood. Conducting tests on accurate dates is necessary to obtain reliable results.

Amniocentesis which is very accurate for the diagnosis of chromosomal anomalies including Down syndrome, is best performed between 16-18 weeks of gestation and it carries a risk of 1 in 200 for miscarriage. Rh negative women will need Rh D immunoglobulin (anti-D).

Chorionic villus sampling is best performed between 10-12 weeks of gestation and carries a 1 in 100 risk of miscarriage, this test is also very much accurate for diagnosis of chromosomal anomalies. Rh negative women need Rh D immunoglobulin (anti-D).

It is best to perform rubella screen before conception than during pregnancy, this is because rubella vaccine is not recommended to be given to a pregnant mother as its a live vaccine.

Glomerular filtration rate (GFR) rises immediately after conception and increases by about 50 per cent overall, reaching its maximum at the end of the first trimester. GFR then falls by about 20 per cent in the third trimester, returning to pre-pregnancy levels within 12 weeks of delivery.

Magnesium Sulphate is the drug of choice in eclamptic patients. A loading dose of 4g magnesium sulphate in 100mL 0.9% saline IVI over 5min followed by maintenance IVI of 1g/h for 24h. Signs of toxicity include respiratory depression and jerky tendon reflexes. In recurrent fits additional 2g can be given. Magnesium should be stopped when the respiratory rate is <14/min, absent tendon reflexes, or urine output is <20mL/h.

Oxytocin is the primary stimulus for uterine involution following childbirth.

Patient in the given case has developed clinical features of mild preeclampsia presented as hypertension, ankle and facial oedema along with proteinuria.

As the fetal lungs are not yet matured, best management in this case would be observing the patient frequently, starting her on steroids and antihypertensive drugs like methyldopa, or labetalol. 31 to 34 weeks of gestation is the optimal gestational age for starting dexamethasone therapy which will help in controlling blood pressure, helps in the maturation of lungs and will also gives time to organise delivery when the lungs are matured.

Immediate C-section is not required at this stage of pregnancy, however a plan for cesarean section must be made to carry it out if the patient develops eclampsia during her stay in the hospital. Immediate vaginal delivery is also not indicated as the pregnancy is far from term. Induced labour will result in fetal demise soon after birth due to the fetal lung immaturity, but immediate delivery has to be considered once the fetal lung attains maturity.

Magnesium Sulphate is indicated only in women with severe pre-eclampsia and even in such cases primary importance is given to blood pressure controlling. Magnesium sulphate is not indicated on this case as the patient is in mild eclampsia.

Even though Paracetamol and deep vein thrombosis prophylaxis are indicated in this case, anticoagulants should be avoided considering the emergency need for surgery.

Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.

There is 70% chance that a women who has had a C-section can deliver via spontaneous vaginal delivery.

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).

In pregnancy, the uterus increases in size to accommodate the developing foetus. At 16 weeks gestation, the fundus of the uterus must be palpated at the midpoint between the umbilicus and the pubic symphysis but the patient’s uterus was already palpable at just 11 weeks.

If less than seven weeks pregnant, it’s unlikely to find a heartbeat by ultrasound. Using transvaginal ultrasound, a developing baby’s heartbeat should be clearly visible by the time a woman is seven weeks pregnant. Abdominal ultrasound is considerably less sensitive, so it can take longer for the heartbeat to become visible. If past seven weeks pregnant, seeing no heartbeat may be a sign of miscarriage.

Fetal viability is confirmed by the presence of an embryo that has cardiac activity. Cardiac activity is often present when the embryo itself measures 2 mm or greater during the 6th week of gestation. If cardiac activity is not evident, other sonographic features of early pregnancy can predict viability.

It is recommended that all pregnant women undergo a routine ultrasound at 10 to 13 weeks of gestation to determine an accurate gestational age. Getting an accurate gestational age is highly important and pertinent for the optimal assessment of fetal growth later in pregnancy. Ultrasound is the most reliable method for establishing a true gestational age by measurement of crown-rump length, which can be measured either transabdominally or transvaginally.

There is a significant increase in oxygen demand during pregnancy due to a 15% increase in the metabolic rate and a 20% increased consumption of oxygen. There is a 40–50% increase in minute ventilation, mostly due to an increase in tidal volume, rather than in the respiratory rate. In a healthy, young human adult, tidal volume is approximately 500 mL per inspiration

Fetal haemoglobin (HBF) is the main haemoglobin type in the foetus and persists after birth for around 6 months. Fetal haemoglobin is composed of two alpha and two gamma subunits The alpha globulin chain is coded for by genes on Chromosome 16. Alpha Thalassemia are therefore associated with Chromosome16 defects The beta and delta globulin chains are coded for by genes on Chromosome 11. Beta and Delta Thalassemia are therefore associated with Chromosome 11 Defects

In pregnancy, term refers to the gestational period from 37 0 to 41 6 weeks. Preterm births occur between 24 0 and 36 6 weeks. 60% of the women will go into labour with in 24 hours in PPROM. After 24 hours have past without any contraction and the gestation age is more than 34 week than prostaglandins can be used to augment labour.

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.

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.

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 perineal membrane (also known as the inferior fascia of the urogenital diaphragm) separates the deep and superficial perineal pouches i.e. it is the inferior border of the deep pouch and superior border of the superficial pouch. The deep perineal pouch is the space therefore between superior and inferior layers of the urogenital diaphragm The superior fascia of the urogenital diaphragm is the superior border

Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously­ normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidy

Maternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two.

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

The World Health Organisation defines the maternal mortality ratio as the number of maternal deaths during a given period per 100,000 live births during the same period. This measure indicates the risk of death in a single pregnancy.

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.

Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.

Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.

BV recurrence rates are high, approximately 80% three months after effective treatment.

Breast infections can be associated with superficial skin or an underlying lesion. Breast abscesses are more common in lactating women but do occur in nonlactating women as well.

The breast contains breast lobules, each of which drains to a lactiferous duct, which in turn empties to the surface of the nipple. There are lactiferous sinuses which are reservoirs for milk during lactation. The lactiferous ducts undergo epidermalization where keratin production may cause the duct to become obstructed, and in turn, can result in abscess formation. Abscesses associated with lactation usually begin with abrasion or tissue at the nipple, providing an entry point for bacteria. The infection often presents in the second postpartum week and is often precipitated in the presence of milk stasis. The most common organism known to cause a breast abscess is S. aureus, but in some cases, Streptococci, and Staphylococcus epidermidis may also be involved.

The patient will usually provide a history of breast pain, erythema, warmth, and possibly oedema. Patients may provide lactation history. It is important to ask about any history of prior breast infections and the previous treatment. Patients may also complain of fever, nausea, vomiting, purulent drainage from the nipple, or the site of erythema. It is also important to ask about the patient’s medical history, including diabetes. The majority of postpartum mastitis are seen within 6 weeks of while breast-feeding

The patient will have erythema, induration, warmth, and tenderness to palpation at the site in question on the exam. It may feel like there is a palpable mass or area of fluctuance. There may be purulent discharge at the nipple or site of fluctuance. The patient may also have reactive axillary adenopathy. The patient may have a fever or tachycardia on the exam, although these are less common.

Incision and drainage are the standard of care for breast abscesses. If the patient is seen in a primary care setting by a provider that is not comfortable in performing these procedures, the patient may be started on antibiotics and referred to a general surgeon for definitive treatment. Needle aspiration may be attempted for abscesses smaller than 3 cm or in lactational abscesses. A course of antibiotics may be given before or following drainage of breast abscesses.

The pudenal nerves has three branches, namely the inferior rectal, perineal and the dorsal nerve of the clitoris. The perineal nerve has two branches: The superficial perineal nerve gives rise to posterior scrotal or labial (cutaneous) branches, and the deep perineal nerve supplies the muscles of the deep and superficial perineal pouches, the skin of the vestibule, and the mucosa of the inferior most part of the vagina. The inferior rectal nerve communicates with the posterior scrotal or labial and perineal nerves. The dorsal nerve of the penis or clitoris is the primary sensory nerve serving the male or female organ, especially the sensitive glans at the distal end.

Nuchal translucency scans and maternal screening tests simply aid in determining a risk percentage for the presence of Trisomy 21, but an accurate diagnosis cannot be reached.

Chorionic villous biopsy (CVB), amniocentesis, and cordocentesis, are all prenatal diagnostic tests that can provide a definitive diagnosis regarding the presence of foetal abnormalities.

Amniocentesis performed at 16 weeks of gestation is associated with the lowest risk for miscarriage and hence is the safest test and should be recommended to the mother (correct answer).

The miscarriage risk from a CVB is at least double the risk following amniocentesis.

Nowadays, cordocentesis is rarely used for sampling of foetal material to detect chromosomal abnormalities as the test poses an even higher risk of miscarriage compared to the other procedures discussed above.

The middle rectal artery arises from the anterior division of the internal iliac artery.

The substructures of the nephrons are mainly located within the cortex. The JGA sits next to the glomerulus in the cortex (click on the magnifying glass of the image to see the arrangement). They play an important role in blood pressure homeostasis as the juxtaglomerular cells produce renin. The descending and ascending limbs of the loop of Henle and collecting ducts have sections within both the cortex and medulla

Stress incontinence is characterized by the involuntary loss of urine with increases in intra-abdominal pressure. It is the most common type of incontinence in younger women, but also occurs in older women. Key risk factors include childbirth, medications that relax the urethral sphincter, obesity, lung disease (from chronic cough), and prior pelvic surgeries. Numerous treatments are available, although few studies compare one treatment with another.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Routine urodynamic tests are not recommended for urinary incontinence. Surgery is reserved for refractory incontinence.

The internal anal sphincter is innervated by pelvic splanchnic nerves

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

Cystic fibrosis is the most common fetal genetic disease in Caucasians and has an autosomal recessive inheritance. It is caused by an abnormal chloride channel due to a defect in the CFTR gene. Complications range from haemoptysis, respiratory failure, biliary cirrhosis, diabetes and male infertility. Men with CF are infertile in 98% of the cases due to failure of development of the vas deference.

With a history of MI, oestrogen and COCP should be avoided. Evening primrose is also not suitable for post-menopausal symptoms. Raloxifene is a SERM – these make hot flushes worse. Clonidine will help improve the hot flushes and the vasomotor symptoms.

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

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

Ectopic pregnancies can quickly become a gynaecological emergency if left untreated. The majority of ectopic pregnancies (95-97%) are tubal occurring in the fallopian tube as opposed to the abdomen, ovary or cervix. In tubal ectopics, the most common site of occurrence is in the ampulla (70%), followed by the isthmus, fimbria, and the cornua.

Androgen insensitivity syndrome means that patients are phenotypically males but they are resistant or insensitive to male androgen hormones. They do not have a uterus. Due to insensitivity to androgens these patients often have female traits but their genetic makeup is of male, 46XY.

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.

Providers should identify any known risk factors for ectopic pregnancy in their patient’s history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment.

Performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy.

Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration.

Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. The patient may have a cervical ectopic pregnancy and would thus run the risk of haemorrhage and potential hemodynamic instability if a dilation and curettage are performed.

Gonadotropin-releasing hormone (GnRH) is the hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.

The pudendal nerve has its origins form S2, S3 and S4 spinal segments. It provides sensation to the clitoris and labia along with the ilioinguinal nerve.

90% of genital candida infections are the result of Candida albicans. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy

The diagnosis of functional ovarian cyst is made when the cyst measures more than 3 cm and rarely grows more than 10 cm. It appears as a simple anechoic unilocular cyst on USS. It is usually asymptomatic. If it is symptomatic then laparoscopic cystectomy should be performed.

The luteinizing hormone (LH) surge during ovulation causes: Increases cAMP resulting in increased progesterone and PGF2 production PGF2 causes contraction of theca externa smooth muscle cells resulting in rupture of the mature oocyte

HPV infects the squamous cells that line the inner surfaces of these organs. For this reason, most HPV-related cancers are a type of cancer called squamous cell carcinoma. Some cervical cancers come from HPV infection of gland cells in the cervix and are called adenocarcinomas.

HPV-related cancers include:

Cervical cancer: Virtually all cervical cancers are caused by HPV. Routine screening can prevent most cervical cancers by allowing health care providers to find and remove precancerous cells before they develop into cancer. As a result, cervical cancer incidence rates in the United States are decreasing.

Oropharyngeal cancers: Most of these cancers, which develop in the throat (usually the tonsils or the back of the tongue), are caused by HPV (70% of those in the United States). The number of new cases is increasing each year, and oropharyngeal cancers are now the most common HPV-related cancer in the United States.

Anal cancer: Over 90% of anal cancers are caused by HPV. The number of new cases and deaths from anal cancer are increasing each year. Anal cancer is nearly twice as common in women as in men. Learn more about anal cancer statistics.

Penile cancer: Most penile cancers (over 60%) are caused by HPV.
Vaginal cancer: Most vaginal cancers (75%) are caused by HPV. Learn about symptoms of, and treatment for, vaginal cancer, a rare type of cancer.

Vulvar cancer: Most vulvar cancers (70%) are caused by HPV.

Preterm birth is the leading cause of neonatal morbidity and mortality not attributable to congenital anomalies or aneuploidy. It has been shown that a shortened cervix is a powerful indicator of preterm births in women with singleton and twin gestations – the shorter the cervical length, the higher the risk of spontaneous preterm birth. Ultrasound measurements of the cervix are a more accurate way of determining cervical length (CL) than using a digital method.

25 mm has been chosen as the ‘cut off’ at above which a cervix can be regarded as normal, and below which can be called short. A cervix that is less than 25 mm may be indicative of preterm birth.

With increasing maternal age, the risk of miscarriage increases. For women between the ages of 40-44, the miscarriage rates sit at about 50% and increases to over 75% for women 45 years and over. The miscarriage rate for women between the ages of 35-39 is 25%.

Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood distributed to the intervillous spaces of the placentae, and 20 per cent to the uterine myometrium.