SPIKES protocol for delivering serious news to patients includes:
– Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
– Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
– Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
– Knowledge:
Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
– Empathy: Express understanding & give support when responding to emotions
– Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.

The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases.  In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal.  When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with.  For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later.  The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.

These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.

This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.

This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.

While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.

Gestational trophoblastic disorder is abnormal conception that is characterised by swollen and oedematous villi with proliferation of the trophoblasts. In a complete mole there is absence of fetal tissue, there is diffuse proliferation of trophoblastic tissue around hydropic villi and on USG it appears as a bunch of grapes or snow storm appearance.

Fetal nutrition is dependant upon multiple factors such as maternal nutritional state, quality of maternal diet, malnutrition, anorexia nervosa, metabolic rate of the mother or whether they suffer from malabsorption syndrome or other related conditions.

Abruptio placentae, defined as a premature separation of the placenta from the uterine wall, is commonly seen with blunt abdominal trauma and can cause fetal distress. It occurs in 1% to 3% of pregnant women with minor trauma and in 40% to 50% with major life-threatening trauma.8,9 Abruption may present with vaginal bleeding, abdominal pain and tenderness, uterine contractions, or fetal distress; however, it may be occult with no vaginal bleeding in up to 20% of cases.

There are 2 treatment options: Spiramycin ASAP if foetus not infected or status of the foetus not known. This reduces risk of transplacental infection. This is continued until term, or until fetal infection is documented. Pyrimethamine, sulfadiazine and folic acid where fetal infection is known e.g. positive amniotic fluid PCR. Monitoring for haemotoxicity required. Pyrimethamine should be avoided in the 1st trimester as teratogenic

Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.

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.

Reduced fetal movements can be the first indication of possible fetal abnormalities. Movements are first perceived by the mother from about 18-20 weeks gestation, increase in size and frequency until 32 weeks gestation when they plateau at about 31 movements per hour. Investigations for reduced fetal heart rate include auscultation of the fetal heart rate using a handheld doppler device, and a cardiotocograph or ultrasound if the foetus is above 28 weeks gestation. About 70% of women who experience one episode of reduced fetal movement have uncomplicated pregnancies. They are advised to report to a maternal unit if another episode occurs.

Urologic injury is the most common injury at the time of either obstetric or gynaecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during caesarean section include previous caesarean delivery, adhesions, emergency caesarean delivery, and caesarean section performed during the second stage of labour.

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.

The urinary bladder is composed of the transitional epithelium, followed by the lamina propria made up of the fibroelastic connective tissue. The muscularis layer covers the lamina propria which is made up of three poorly defined layers of smooth muscles; the inner longitudinal, middle circular and the outer longitudinal layer. The bladder is covered on the superior surface and the lateral surface by the peritoneum.

Patient’s symptoms and signs are suggestive of round ligament strain, which is a normal finding during pregnancy, especially in the 2nd trimester, and it does not require any medical intervention.

Round ligament is a rope-like fibromuscular band which extends from the anterolateral aspect of uterus anteriorly between the layers of the broad ligament, and passing through the deep inguinal ring into the inguinal canal.
A sharp, sudden spasm in the right iliac fossa which lasts for a few seconds which is usually triggered by sneezing, coughing, laughing and rolling over in bed are the common presentations of a round ligament pain.

Ectopic pregnancy and rupture of ectopic pregnancy are two unlikely diagnosis in this patient as she is in the second trimester of her pregnancy, whereas both the mentioned conditions occur during the first trimester.

Although appendicitis presents with pain in right iliac fossa, the pain is not causes by coughing or sneezing. Also, there will be other symptoms like tenderness and rebound tenderness in right iliac fossa in case of appendicitis.

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.

Hysterosalpingography is used to assess the patency of the fallopian tubes. It is performed by injection of a radio-opaque iodine based contrast. This test is contraindicated in pelvic inflammatory disease and during pregnancy. Should be performed in Follicular phase of menstrual cycle after cessation of menstrual bleeding and prior to ovulation (days 6-12).

The corpus luteum is formed from the granulosa cells of the mature follicle. The structure functions as a transient endocrine organ which secretes mainly progesterone with additional secretion of oestradiol and inhibin, which serve to suppress FSH levels. In the event of no pregnancy, the corpus luteum stops producing progesterone and degenerates into the corpus albicans.

In Cushing’s syndrome there is excess cortisol. Causes are broadly divided into 2 types: ACTH dependent disease: excess ACTH from the pituitary (Cushing’s disease), ectopic ACTH-producing tumours or excess ACTH administration. Non-ACTH-dependent: adrenal adenomas, adrenal carcinomas, excess glucocorticoid administration. The recommended diagnostic tests for the presence of Cushing’s syndrome are 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test and late-night salivary cortisol. There are several other tests that may also be performed to find the cause. ACTH and cortisol measured together may show if this is ACTH dependent or not. MRI pituitary and CT abdo and pelvis may show if tumour is the cause.

Visual disturbances although very common during pregnancy are not a normal sign. Physicians should have a firm understanding of the various ocular conditions that might appear pregnancy or get modified by pregnancy. In addition, it is very important to be vigilant about the rare and serious conditions that may occur in pregnant women with visual complaints. Prompt evaluation may be required and the immediate transfer of care of the patient may help saving the lives of both the mother and the baby.

Ilioinguinal nerve injury is one of the most common nerve injuries associated with pelvic surgery.

The patient is suffering from Bartholin cyst abscess.
Insertion of an inflatable balloon is a non-surgical procedure that can be performed as an outpatient using a local anaesthetic (LA) injection to numb the area. It involves making a passage from the cyst or abscess through which the pus can drain over 4 weeks. After the LA injection, a small skin cut is made into the cyst or abscess, which allows drainage. A fluid/ pus swab sample may be taken to check for an infection at this stage. A cotton bud is used to break the pockets of abscess/ cyst fluid. A flexible tube (called a Word catheter) with a small, specially designed balloon at its tip is then inserted into the cyst or abscess to create a passage. The balloon is inflated with 3–4mls of sterile fluid to keep the catheter in place. Rarely, a stitch may be used to partly close the cut and hold the balloon in position. It is then left in place for up to 4 weeks; new skin to forms around the passage and the wound heals.

Marsupialization can be done for drainage but is inferior or word catheter because of the technical challenges and complications. Hot compressions and analgesics alone do not suffice in the presence of an abscess. Antibiotics are given after drainage but are not effective alone when there is a large collection of pus.

The following hormones are excreted from the anterior pituitary gland: TSH, GN, ACTH, LH, FSH, MSH, PRL.
Human chorionic gonadotropin (hCG, or human chorionic gonadotrophin) is a placental hormone secreted by syncitiotrophoblasts during the second week of gestation.

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

This infant will most likely be diagnosed as having fetal hydantoin syndrome, which occurs due to an in utero exposure to antiepileptic drugs like phenytoin, carbamazepine, valproate etc. 

Multiple antiepileptics, due to their ability to cross placenta, have teratogenic effects which will result in low folate and high oxidative metabolite levels in the fetus. This likely combined effect results deformities like cleft lip and palate, wide anterior fontanelle, distal phalangeal hypoplasia and cardiac anomalies like pulmonary stenosis, aortic stenosis etc in the fetus. There will be developmental delay and poor cognitive outcomes as a result of neural tube defects and microcephaly associated with this. Therefore, prior to conception, those patients who require antiepileptics for seizure control during pregnancy should titrate it to the lowest dose and must started on high-dose (4 mg) folic acid supplementation to minimize the risk of such congenital malformations.

Fetal alcohol syndrome commonly presents with microcephaly and midfacial hypoplasia, but is not association with cleft lip or palate.

Cocaine use during pregnancy can be associated with preterm delivery, abruptio placentae and fetal growth restriction; but there is no evidence to prove its association with congenital defects.

Fetal renal failure with associated oligohydramnios that results in pulmonary hypoplasia, growth restriction, and limb defects are the complications associated with the use of lisinopril and other angiotensin-converting enzyme inhibitors during pregnancy; but it does not cause cleft lip or palate.

Most infants with congenital syphilis are asymptomatic at birth and those with symptoms typically have rhinitis or “snuffles, hepatomegaly and a maculopapular rash none of which are seen in this patient.

Fetal hydantoin syndrome results from the in-utero exposure to antiepileptic drugs like phenytoin, carbamazepine etc and is usually presented with microcephaly, a wide anterior fontanelle, cleft lip and palate, and distal phalangeal hypoplasia.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.

After perineal repair, lactulose and a bulking agent should ideally be given for 5-10 days as well as broad spectrum antibiotics should be given that will cover all possible anaerobic bacteria. At 6-12 months a full evaluation should be done regarding the progress of healing. 60 to 80% of women are asymptomatic 12 months post delivery and external anal sphincter repair.

The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. Pregnancy is a state of increased requirement of macro and micronutrients, and malnourishment or inadequate dietary intake before and during pregnancy, can lead to adverse perinatal outcomes. Many nutritional interventions have been proposed for pregnant mothers. These include multiple micronutrients (MMN), iron/folate, balanced protein energy, calcium, zinc and folic acid supplementation.

The extrinsic pathway is activated by the tissue factor, which converts factor VII to VIIa which later on converts factors X and II to their activated form finally leading to the conversion of fibrinogen to fibrin fibres.

Turner syndrome patients present with primary amenorrhea. These ladies have non functional or streak ovaries and they cant conceive. Their genetic traits is 45X. They have a shielded chest, webbed neck and low height. These patients suffer from primary amenorrhea.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor.

These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

All other options are incorrect.

To provide suitable advice to this couple, the candidate must be aware of the following facts:
Because the luteal phase is 14 days long, regardless of the follicular phase length, ovulation happens 14 days before the period.
As a result, ovulation in this lady might have occurred as early as day 12 or as late as day 15 of her cycle.
In the presence of adequate and normal cervical mucus, sperm survival has been demonstrated to be far longer than previously thought, with intercourse occurring up to 6 days before the known period of ovulation, resulting in pregnancy.
Intercourse should be stopped six days before the earliest ovulation in this woman (i.e. on day six).
– It is generally accepted that the ovulated egg can be fertilised for approximately 24-36 hours.
Intercourse should not be restarted for at least two days after the most recent ovulation.
This would be day 17 for this woman.
Between days 6 and 17 of the cycle, abstinence is required.

Changes in the cardiovascular system in pregnancy are profound and begin early in pregnancy, such that by eight weeks’ gestation, the cardiac output has already increased by 20%. The primary event is probably peripheral vasodilatation. This is mediated by endothelium-dependent factors, including nitric oxide synthesis, upregulated by oestradiol and possibly vasodilatory prostaglandins (PGI2). Peripheral vasodilation leads to a 25–30% fall in systemic vascular resistance, and to compensate for this, cardiac output increases by around 40% during pregnancy. 

Fetal heart rate tracings (FHR) under category I include all of the following:
– baseline rate 110– 160 bpm
– baseline FHR variability moderate
– accelerations present or absent
– late or variable decelerations absent
– early decelerations present or absent

The onset of fetal bleeding is marked by a tachycardia followed by a bradycardia with intermittent accelerations or decelerations. Small amounts of vaginal bleeding associated with FHR abnormalities should raise the suspicion of fetal haemorrhage. This condition demands prompt delivery and immediate reexpansion of the neonatal blood volume.

The neck of the bladder is surrounded by the internal sphincter. It is supplied by the sympathetic and parasympathetic nerves of the splanchnic nerve. Parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. It Is predominantly by the parasympathetic nerves S2-S4. Relaxation of the bladder is caused by inhibiting the sacral parasympathetic preganglionic neurons and exciting the lumbar sympathetic preganglionic neurons. Remember SYMPATHETIC is for STORAGE and PARASYMPATHETIC is for PEEING.

B-HCG levels almost double every 48 hours. A B-HCG levels of less than 5 mIU/ml is considered negative and anything above 25 is considered positive. As the foetus was not visualized on ultrasound in the uterus, there is possibility that this might be an ectopic pregnancy. But since the B-HCG levels also continued to fall the pregnancy becomes non-viable.

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.

After the release of the oocyte, the theca and the granulosa cells form the corpus luteum which undergoes extensive vascularization for continued steroidogenesis. Progesterone is secreted by the luteal cells and is synthesized from cholesterol.

The blastocyst hatchs from the Zona Pellucida

Contraindications of PROVERA (medroxyprogesterone acetate) include: undiagnosed abnormal genital bleeding, known, suspected, or history of breast cancer, known or suspected oestrogen- or progesterone-dependent neoplasia, active DVT, pulmonary embolism, or a history of these conditions, active arterial thromboembolic disease (for example, stroke and MI), or a history of these conditions, known anaphylactic reaction or angioedema, known liver impairment or disease, known or suspected pregnancy.

WHO defines perinatal death as the number of still births and death in the first week of life per 1000 births.

Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.

As there has been no bleeding or expulsion of the products of conception this is a missed miscarriage

Hysterosalpingography is a radiological test used to investigate infertility especially in patients with no history suggesting tubal blockages such as pelvic surgery or PID, in which case a laparoscopy and dye is better suited. For the procedure, a contrast dye is inserted through the cervix, flows through the uterus and the fallopian tubes and should spill into the peritoneum. Fluoroscopy provides dynamic images of these structures to determine if there are any abnormalities or blockages. HSG is best performed on day 6-12 in the cycle, after the cessation of menses, and before ovulation, to avoid X Ray exposure in case of an unknown early pregnancy.

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

It is essential to notice the important details mentioned in the case scenario. These would be the details about her menstruation, a smaller than dates uterus and an open cervix. A smaller than expected uterine size could be caused by her passing out some tissue earlier or it could be due to the foetus having been dead for some time. The finding of an open cervix would be in line with the fact that she had passed out some fetal tissue or it could signify that she is experiencing an inevitable miscarriage (while all fetal tissue is still kept within her uterus).

The likely diagnoses that should be considered for this case would be miscarriage (threatened, incomplete, complete and missed), cervical insufficiency, and ectopic pregnancy. A smaller than dates uterus and an open cervix makes threatened abortion an unlikely diagnosis. Her clinical findings could be expected in both an incomplete abortion and a complete abortion.
In ectopic pregnancy, although there would be a smaller than dates uterus, the cervical os would usually be closed. Cervical insufficiency is probable due to an open os but the uterine size would be expected to correspond to her dates, making it also less likely than a miscarriage.

Since she most likely has had a miscarriage (be it incomplete or complete), the next best step would be to do a per vaginal ultrasound scan which could show whether or not products of conception are still present within the uterine cavity. If present, it would be an incomplete miscarriage which would warrant a dilatation and curettage; if absent, it is a complete miscarriage so D&C would not be needed.

In view of her open cervix and 12 weeks of amenorrhea, there is no indication for a pregnancy test nor assessment of her beta-hCG levels. Cervical ligation would only be indicated if the underlying issue was cervical incompetence, which is not in this case.

The best strategy is to commence cyclical hormone therapy using continuous daily oestrogen therapy, with medroxy progesterone acetate (MPA) given daily for 12 days each month.

This patient is most likely experiencing menopause, with symptoms caused by her oestrogen deficiency state.

Diazepam will help her to sleep and possibly alleviate her irritability, but would be unlikely to relieve the hot flushes.

Continuous therapy with oestrogen and MPA provides continuous progestogen therapy and has a high risk of causing unpredictable breakthrough vaginal bleeding, as it is only three months since the last menstrual period. This treatment is not recommended to be given within 1 – 2 years of the last period.

Oestrogen alone is not recommended for women who still have their uterus.

Progestogen alone would only be indicated in cases with contraindications to oestrogen administration.

WHO guidelines
Semen volume: Greater than or equal to 1.5 ml
pH: Greater than or equal to 7.2
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
Total sperm number: 39 million spermatozoa per ejaculate or more
Total motility (% of progressive motility and nonprogressive motility): 40% or more motile or 32% or more with progressive motility
Vitality: 58% or more live spermatozoa
Sperm morphology (percentage of normal forms): 4% or more

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.

SLE is a type III hypersensitivity reaction

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.

Luteal phase is always fixed to 14 days. In this patient, ovulation will occur between days 12-15. Sexual encounter must be ceased until 24-36 hours before day 15 (day 17). The start date of abstinence, calculated by decreasing 6 days (life span of the sperm) from the earliest possible day of ovulation (12-6=6). Hence from day 6-17, sexual encounter must be avoided.

Menopause is defined as the cessation of menstruation for a period of 12 months. Premature menopause is defined as cessation of menstruation before the age of 40.