The most common gram negative diplococci include Neisseria, haemophilus and Moraxella.

Patient mentioned in the case has developed severe nausea and vomiting at the initial weeks of pregnancy. If the following clinical features are present, it confirms the diagnosis of hyperemesis gravidarum:
– Weight loss of more than 5% of pre-pregnancy weight
– Moderate to severe dehydration.
– Ketosis
– Electrolyte abnormalities.

Management of hyperemesis gravidarum include:
– Temporary suspension of oral intake, followed by gradual resumption.
– Intravenous fluid resuscitation, beginning with 2 L of Ringer’s lactate infused over 3 hours to maintain a urine output of more than 100 mL/h.
– Use of Antiemetics like metoclopramide, if needed.
– Oral administration of Vitamin B6.
– Replacement of electrolytes if required in the case.

Encouraging oral intake and sending this patient home without any intravenous hydration, is not considered the correct treatment option in this case.

Detrusor contraction is via Parasympathetic innervation of pelvic splanchnic nerves (S2-4). This also causes relaxation of the internal urethral sphincter Note contraction and relaxation of the external urethral sphincter is under somatic control.

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

The posterior scrotal artery is a terminal branch of the perineal artery which is a branch of the internal pudendal artery.

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

2010 FIGO classification of cervical carcinoma

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

The lower vagina drains to the inguinal nodes where as the upper vagina drains to the internal and external iliacs

Pelvic inflammatory disease (PID) is a known risk factor in causing tubal infertility due to its role in tubal damage. The tubal infertility rate after one episode of PID is thought to be about 12.5%. After two episodes the risk increases to 25%, and 50% after three episodes. The usual causative agents are chlamydia and gonorrhoea.

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

Maternal blood volume expands during pregnancy to allow adequate perfusion of vital organs, including the placenta and foetus, and to anticipate blood loss associated with delivery. The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. While there is some increase in intracellular water, the most marked expansion occurs in extracellular fluid volume, especially circulating plasma volume. This expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Overall, total body water increases from 6.5 to 8.5 L by the end of pregnancy.

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.

There are over 100 genotypes of HPV including several other high risk HPV types. HPV 16 and 18 are responsible for 70% of cases of HPV related cancers. HPV is thought to induce cancer via onco-proteins. The primary onco-proteins are E6 and E7 which inactivate two tumour suppressor proteins, p53 (inactivated by E6) and pRb (inactivated by E7)

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

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.

Polycystic ovary syndrome (PCOS) is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. The name polycystic ovary syndrome describes the numerous small cysts (fluid-filled sacs) that form in the ovaries. However, some women with this disorder do not have cysts, while some women without the disorder do develop cysts.

The symptoms of PCOS may include:
– Missed periods, irregular periods, or very light periods
– Ovaries that are large or have many cysts
– Excess body hair, including the chest, stomach, and back (hirsutism)
– Weight gain, especially around the belly (abdomen)
– Acne or oily skin
– Male-pattern baldness or thinning hair
– Infertility
– Small pieces of excess skin on the neck or armpits (skin tags)
– Dark or thick skin patches on the back of the neck, in the armpits, and under the breasts

The so-called Laurence-Moon-Biedl syndrome is a fairly rare condition characterized by six cardinal signs, namely obesity, atypical retinitis pigmentosa, mental deficiency, genital dystrophy, polydactylism and familial occurrence.

Froehlich syndrome is characterized by increased or excessive eating that leads to obesity, small testes, and a delay in the onset of puberty. It is also common for children with Froehlich syndrome to experience the delay in physical growth and the development of secondary sexual characteristics.

Cushing’s syndrome is a disorder that occurs when your body makes too much of the hormone cortisol over a long period of time. Cortisol is sometimes called the “stress hormone” because it helps your body respond to stress. Cortisol also helps. maintain blood pressure. regulate blood glucose, also called blood sugar.

Pseudohypoparathyroidism is characterized by short stature, a round face, short neck, and shortened bones in the hands and feet. Intelligence usually ranges from low normal to mentally retarded. Headaches, weakness, tiring easily, lethargy, cataracts and blurred vision or hypersensitivity to light may also be present.
This patient’s condition can only be explained by PCOS.

Threatened abortion consists of any vaginal bleeding during early pregnancy without cervical dilatation or change in cervical consistency. Usually, no significant pain exists, although mild cramps may occur. More severe cramps may lead to an inevitable abortion.

Threatened abortion is very common in the first trimester; about 25-30% of all pregnancies have some bleeding during the pregnancy. Less than one half proceed to a complete abortion. On examination, blood or brownish discharge may be present in the vagina. The cervix is not tender, and the cervical os is closed. No fetal tissue or membranes have passed. The ultrasound shows a continuing intrauterine pregnancy. If an ultrasound was not performed previously, it is required at this time to rule out an ectopic pregnancy, which could present similarly. If the uterine cavity is empty on ultrasound, obtaining a human chorionic gonadotropin (hCG) level is necessary to determine if the discriminatory zone has been passed.

Placenta previa is an antenatal complication occurring around the third trimester of pregnancy. The cervix is closed in this condition which rules out inevitable abortion and the patient has no history of passage of tissue, this rules out complete abortion. The patient has no history of fever or offensive vaginal discharge which makes septic abortion unlikely.

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

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.

SLE is a type III hypersensitivity reaction

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

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. Weight of the uterus increases from 50–60 g prior to pregnancy to 1000 g by term.

Thyroid function in pregnancy is altered in two ways; the circulating levels of the thyroid binding proteins are increased, resulting in an increase in the total circulating levels of thyroid hormones (but a slight fall in the free component).

It is classified under type II hypersensitivity reaction. Antibodies are formed against the rhesus antigen i.e. D antigen. Hence when the Antibody reacts with the antigen on the RBC it results in activation of the complement cascade leading to lysis.

it is imperative to elucidate the patient’s risk for current pregnancy and time within her current menstrual cycle prior to IUD insertion. A negative urine pregnancy test is a prerequisite to placement of an IUD. Pregnancies occurring with IUDs in place have an increased incidence of complications, including spontaneous abortion and septic abortion.

For this reason, many providers prefer to time IUD insertion within the first 5-7 days of the menstrual cycle, further assuring that the patient is not newly pregnant.

All other options take risk of the patient being pregnant.

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

The number of stillbirths and deaths in the first week of life per 1000 births.
According to WHO the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.

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

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 Rotterdam criteria was developed and expanded by the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine Rotterdam consensus (ESHRE/ASRM) in 2003 and is now the Gold standard in the diagnosis of PCOS. The criteria requires two of three features: anovulation, hyperandrogenism, and polycystic ovaries seen on ultrasound.

The National Institute of Child Health and Human Development (NICHD) attempted to define PCOS in 1990 but omitted ultrasonographic evidence of polycystic ovaries which is considered to be diagnostic of PCOS.

The Androgen Excess Society (AES) served to confirm hyperandrogenism as the central event in the development of PCOS.

The ROME III criteria is used for Irritable Bowel Disease and is therefore not applicable to PCOS.

The WHO defines maternal death as female death from any cause related to pregnancy or its management, including childbirth or within 42 days of termination of pregnancy. This is irrespective of the duration or site of the pregnancy.

The contents of the broad ligament:
Fallopian tubes
Ovarian artery
Uterine artery
Ovarian ligament
Round ligament of uterus

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to rapid and severe haemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labour or rapid forceful labour, especially if stimulated.

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

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

History of amenorrhoea, abdominal and vaginal examination are more favour of ectopic pregnancy. Endometriosis usually has a chronic cause and dysmenorrhoea. Salpingitis usually presents with fever. Ovarian torsion and ovarian tumours have different clinical presentations.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. Though the primary host for the organism is the domestic cat, humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection which can lead to hydrocephalus, microcephaly, mental disability and vision loss.

In the foetus, the hypogastric artery ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

The syndrome with which the woman was diagnosed is an autoimmune, hypercoagulable state which most possibly was the reason of her previous miscarriages. This is the reason why she should be on aspirin and heparin in order to prevent any future miscarriage.

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.

Serous tumours of the ovaries are large, cystic and spherical to ovoid in shape. They can be benign or malignant. Malignant tumours are usually nodular with irregularities in the surface where the tumour penetrates into the serosa. Psammoma bodies are a histological identification for these tumours which appear in the tips of the papillae.

Chorioamnionitis is a complication of pregnancy caused by bacterial infection of the fetal amnion and chorion membranes. Group B Streptococcus is associated with chorioamnionitis

Thelarche means appearance of the breast tissue under the influence of oestrogen from the ovaries. It heralds the onset of puberty among girls. It is followed by an increase in growth velocity followed by menarche which is the time of first menstrual bleeding.

Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.

This is Linea Nigra. It occurs in 3/4 of pregnancies and is due to increased melanocyte-stimulating hormone production by the placenta. This also causes melasma and darkening of the nipples.

The anal sphincters are responsible for closing the anal canal to the passage of faeces and flatus. The smooth muscle of the involuntary internal sphincter sustains contraction to prevent the leakage of faeces between bowel movements and is innervated by the pelvic splanchnic nerves, which are a branch of the spinal segment 4. The external sphincter is made up of skeletal muscle and can therefore contract and relax voluntarily. Its innervation comes from the inferior rectal branch of the pudendal nerve, and the perineal branch of S4 nerve roots.

The rectus sheath is formed by the decussation and interweaving of the aponeuroses of the fl at abdominal muscles. The external oblique aponeurosis contributes to the anterior wall of the sheath throughout its length. The superior two thirds of the internal oblique aponeurosis splits into two layers (laminae) at the lateral border of the rectus abdominis; one lamina passing anterior to the muscle and the other passing posterior to it. The anterior lamina joins the aponeurosis of the external oblique to form the anterior layer of the rectus sheath. The posterior lamina joins the aponeurosis of the transversus abdominis to form the posterior layer of the rectus sheath.

Oxytocin binds to the G protein coupled receptors that triggers the IP3 mechanism leading to an elevated intracellular calcium ion.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.

These are the most common ovarian tumours in young women. The most common form is the mature dermoid cyst (cystic teratoma). It can consist of a combination of all the type of tissues (mesenchymal, stromal and epithelial). Any mature tissue type can be present such as muscle, cartilage, bone, teeth and often hair. Treatment is cystectomy.

Spontaneous abortion is the loss of pregnancy naturally before twenty weeks of gestation. Colloquially, spontaneous abortion is referred to as a ‘miscarriage’ to avoid association with induced abortion. Early pregnancy loss refers only to spontaneous abortion in the first trimester. In 50% of cases, early pregnancy loss is believed to be due to fetal chromosomal abnormalities. Advanced maternal age and previous early pregnancy loss are the most common risk factors. For example, the incidence of early pregnancy loss in women 20-30 years of age is only 9 to 17%, while the incidence at 45 years of maternal age is 80%. Other risk factors include alcohol consumption, smoking, and cocaine use.

Several chronic diseases can precipitate spontaneous abortion, including diabetes, celiac disease, and autoimmune conditions, particularly anti-phospholipid antibody syndrome. Rapid conception after delivery and infections, such as cervicitis, vaginitis, HIV infection, syphilis, and malaria, are also common risk factors. Another important risk factor is exposure to environmental contaminants, including arsenic, lead, and organic solvents. Finally, structural uterine abnormalities, such as congenital anomalies, leiomyoma, and intrauterine adhesions, have been shown to increase the risk of spontaneous abortion.

Cardiotocography, also known as the non-stress test is used to monitor fetal heartbeat and uterine contractions of the uterus. An abnormal CTG may indicate fetal distress and prompt an early intervention. Variability refers to the variation in the fetal heartbeat form one beat to another. Normal variability is between 5-25 beats per minute while an abnormal variability is less than 5 bpm for more than 50 minutes, or more than 25 bpm for more than 25 minutes.

This patient is most likely to have a ruptured ectopic pregnancy. The history of multiple TOPs suggests her contraceptive methods are not reliable and her missed period is suggestive she may currently be pregnant. There is no temperature or vaginal discharge to suggest PID though this is of course possible as is appendicitis. The last termination was 6 months ago so endometritis is unlikely.

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extra pelvic endometriosis may rarely occur.

Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Though ESR maybe elevated due to the presence of inflammation, it is not specific for endometriosis and has no role in preoperative staging. The same holds true for any possible CBC finding.

Transvaginal ultrasound is preferred for diagnosis but doesn’t aid in preoperative staging of endometriosis.

CA125 values are elevated in severe infiltrative endometriosis but unchanged in mild disease. Relaying on CA125 cause a high rate of false negatives.

There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria

The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.

Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.

Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.

At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.

All non-sensitised RhD negative women should receive Anti-D IgG within 72 hours following abortion

The gestational sac is typically visible from 31 days gestation by transvaginal ultrasound and a week later (38 days) on transabdominal ultrasound.

A pH value below than 7.18 indicates acidosis which can result in hypoxic brain injury. In order to prevent brain injury, immediate delivery of the foetus should be planned. The normal range for a term baby is pH: 7.18 – 7.38, preterm pH: 7.14 – 7.4.

The proximal attachment of the piriformis muscles is from the anterior surface of sacrum and it attaches distally to the superior border of the greater trochanter of the femur. It is innervated by the anterior rami of S1 and S2.

Folate has been in the news because of its connection with a type of birth defect called neural tube defect. Studies have shown that women who have infants with neural tube defects have lower intakes of folate and lower blood folate levels than other women. Folate is needed early in pregnancy (before many women know they are pregnant) for normal neural tube development.

Many vegan foods including enriched bread, pasta, and cold cereal; dried beans; green leafy vegetables; and orange juice are good sources of folate. Vegan diets tend to be high in folate, however, to be on the safe side, women capable of becoming pregnant should take a supplement or use fortified foods that provide 400 micrograms of folate daily.

For the above mentioned reasons, all other options are incorrect.

The Sella turcica is composed of three parts:
1. The tuberculum sellae (horn of saddle): a variable slight to prominent median elevation forming the posterior
boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.
2. The hypophysial fossa (pituitary fossa): a median depression (seat of saddle) in the body of the sphenoid that accommodates the pituitary gland (L. hypophysis).
3. The dorsum sellae (back of saddle): a square plate of bone projecting superiorly from the body of the sphenoid.
It forms the posterior boundary of the Sella turcica, and its prominent superolateral angles make up the posterior clinoid processes.

First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour in a British journal was having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.

Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.

Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.

Predisposing factors of preterm delivery include a short cervix (or if it shortens earlier than in the third trimester), urinary tract or sexually transmitted infections, open cervical os, and history of a previous premature delivery. Increased uterine size can also contribute to preterm delivery and is seen with cases of polyhydramnios, macrosomia and multiple pregnancies. The shorter the cervical length, the greater the risk of a premature birth.
In this case, the risk of bacterial vaginosis and candidiasis contributing to preterm delivery would be lower than if in the context of an open cervical os. However, the risk of premature delivery is significantly increased if it is found that the fetal fibronectin test is positive, even if the os is closed.

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

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

The endometrium is lined by columnar epithelium

Folic Acid should be increased in diet of a pregnant women. Deficiency will lead to neural tube defects i.e. spina bifida.

Congenital rubella infection that occurs after 16 weeks gestation does not typically cause fetal abnormalities. This however plays no part in vaccination advice. Rubella vaccine is live and should not be given during pregnancy. The mother should be offered vaccination after giving birth. It is safe for the vaccine (typically given as combined MMR) to be administered if the mother is breastfeeding.

The most common causative agent found in female urinary tract infections is Escherichia Coli. E. Coli is a bacteria found in the environment and the human gastrointestinal system. Other common causes of UTI include Klebsiella sp, Proteus sp and various Enterococci.

Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.

Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area.

The treatment of stage 1A cervical cancer is excision of the margins using the Loop electrical excision procedure (LLETZ). Hysterectomy is not necessary. This treatment enables fertility to be preserved.

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

Bacterial vaginosis is the most common cause of acute vaginitis, accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal vaginal flora- Mixed vaginal flora is considerably more common as a cause of vaginal discharge than – albicans and T. vaginalis.

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

Testing for beta hCG should be the first test in this case. It will rule out any pregnancy that is strongly suspected based on the patient’s history and physical examination.

The normal fetal heart rate is between 110-150 bpm.

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

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

An endometrioma, also known as a chocolate cyst is a benign ovarian cyst that occurs as a result of the trapping of endometriosis tissue inside the ovary. The findings on transvaginal ultrasound are often a unilocular cyst, with ground glass echogenicity due to haemorrhage. Other benign masses that can be evaluated using transvaginal ultrasound are functional cysts, serous and mucinous cystadenomas and mature teratomas.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

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.

The episiotomy is a technique originally designed to reduce the incidence of severe perineal tears (third and fourth-degree) during labour. The general idea is to make a controlled incision in the perineum, for enlargement of the vaginal orifice, to facilitate difficult deliveries.

Below is the classification scale for the definitions of vaginal tears:
First degree involves the vaginal mucosa and perineal skin with no underlying tissue involvement.
Second degree includes underlying subcutaneous tissue and perineal muscles.
Third degree is where the anal sphincter musculature is involved in the tear. The third-degree tear can be further broken down based on the total area of anal sphincter involvement.
Fourth degree is where the tear extends through the rectal muscle into rectal mucosa.

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.

There is an increase risk of developing carcinoma of the uterus, if the endometrium shows hyperplasia with atypia. The standard surgery is total hysterectomy with bilateral salpingectomy which can be performed abdominally or laparoscopically If the disease is grade 1-2 and less than 1B i.e. less than 50% invasion of the uterine body.

Retarded skeletal growth resulting in small for gestational age babies are the usual outcomes of an untreated vitamin D deficiency in pregnancy.

Symptoms associated with maternal vitamin D deficiency during pregnancy are:
– Hypocalcemia in newborn.
– Development of Rickets later in life.
– Defective tooth enamel.
– Small for gestational age due to its effect on skeletal growth
– Fetal convulsions or seizures due to hypocalcemia.

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

Nipple stimulation during breastfeeding triggers the production of oxytocin from the hypothalamus and its subsequent release from the posterior pituitary gland. The hormone causes the myoepithelial cells of the breast to contract causing milk to flow through the ducts.

Ergometrine and Prostaglandin E2 are used during labour to control uterine bleeding after delivery, or ripen the cervix, while Atosiban is an oxytocin antagonist.

Antidiuretic hormone is also released from the posterior pituitary, and acts on the kidneys to decrease fluid excretion.

Fetal ultrasound scanning is considered an essential part of routine antenatal care with first trimester scans recommended for confirming viability, accurate estimation of gestational age and determining the number of foetuses. Fetal crown-rump length (CRL) is measured in early pregnancy primarily to determine the gestation age (GA) of a foetus and is most reliable between 9+0 to 13+6 weeks’ gestation, but not beyond.

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

Disseminated intravascular coagulation (DIC) in pregnancy is the most common cause of an abnormal haemorrhage tendency during pregnancy and the puerperium. Although pregnancy itself can cause DIC, its presence is invariably evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead foetus, amniotic fluid embolism, placental retention or bacterial sepsis.

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic women.

In the management of postpartum haemorrhage, it is essential that the bleeding is first mechanically prevented, followed by the administration of oxytocic drugs, which cause the uterine smooth muscle to contract and clamping off bleeding sites in the endometrium. The drug of choice in the treatment protocol of PPH is 5 units of syntocin, a synthetic oxytocin uterotonic, by slow intravenous infusion. This is particularly suitable in the case of uterine atony. Other uterotonics, misoprostol, carboprost, ergometrine, can be used, but are not as effective in an emergency setting.

Diagnostic hysteroscopy with dilatation and curettage (D&C) is the most suitable step for immediate management of this patient (correct answer). This would aid in determining if an endometrial lesion exists and enable histologic examination of any endometrium that may be present.
Assessment of endometrial thickness via ultrasound examination is commonly used to decide if a patient requires D&C. In postmenopausal women, an endometrial thickness of more than 4mm indicates need for D&C.

However, this method is more beneficial in younger postmenopausal women. In women who are 70 years or older, postmenopausal bleeding should be considered to be due to a malignancy until confirmed otherwise.

In this patient, a vaginal swab for culture or a colposcopy would not be appropriate.

Similarly, laparoscopy is not indicated unless the bleeding continued despite a normal hysteroscopy and D&C.

If the endometrial thickness is less than 4mm, a malignancy is less likely to be present; however, the risk cannot be completely excluded.

When it comes to questions on venous drainage the ovarian vein is likely to be a common question given its varied drainage depending on laterality. 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.

Congenital Herpes Simplex Virus infection may cause high levels of morbidity and mortality in neonates. Risk of infection with HSV 1 and 2 is highest within 6 weeks of delivery and is transferred to the neonate via maternal secretions at birth. Affected babies can present as skin manifestations, CNS infection, or disseminated infection, which carries an 85% risk of mortality if left untreated. Treatment with high dose antivirals such as acyclovir can help decrease the case mortality rate to 30% in cases of disseminated infection.

Contracted pelvis occurs when one or more of its diameters is reduced so that it interferes with the normal mechanism of labour. A transverse diameter below 11 cm will result in difficult delivery of the foetus and C-section will be the better option in that case

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

Miscarriage rates:
20-24 – 9%
25-29 – 11%
30-34 – 15%
35-39 – 25%
40-44 – 51%
>45 – 75%

6 and 11 are considered low risk and are commonly associated with genital warts and low-grade squamous intraepithelial lesions of the cervix (can correspond cytologically to CIN 1)

Shortly after the morula enters the uterus, around the 4th day after fertilization, a clear cystic cavity starts forming inside the morula. The fluid passes through the zona pellucida from the uterine cavity and hence forms the blastocyst.

Urinary incontinence can be divided into two main aetiologies, stress incontinence, or overactive bladder. Conservative management include lifestyle interventions, controlling fluid intake, or bladder exercises. If conservative management is no longer efficient, then medications may be indicated. Oxybutynin is an anticholinergic drug used in the treatment of urinary incontinence. As with other anticholinergic drugs, side effects include dry mouth, dry eyes, blurry vision and constipation. About 1 in 10 patients taking Oxybutynin will experience some of these side effects.

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.

The transabdominal ultrasound uses a frequency of 3.5-7 MHz emitted from a transducer. Transvaginal 5-7.5 MHz (post bladder void.

Small teeth with faulty enamel is more associated with fetal alcohol syndrome (FAS).

In FAS, the most common orofacial changes are small eyelid fissures , flat facies, maxillary hypoplasia, short nose, long and hypoplastic nasal filter, and thin upper lip. The unique facial appearance of FAS patients is the result of changes in 4 areas: short palpebral fissures, flat nasal bridge with an upturned nasal tip, hypoplastic philtrum with a thin upper vermillion border, and a flat midface. Other facial anomalies include micrognathia, occasional cleft lip and/or palate and small teeth with defective enamel.