The average volume of uterine blood flow at term is 500-750 ml/min.

Vascular spiders or angiomas, are of no clinical significance during pregnancy as these are common findings and are form as a result of hyperestrogenemia associated with normal pregnancies. These angiomas, as they will resolve spontaneously after delivery, does not require any additional workup or treatment.
Reassurance to the patient is all that is required in this case.

The mid-luteal progesterone sample should be taken 7 days before the expected period i.e. day 21 in a 28-day cycle or day 28 of a 35 day cycle

Cervical ectropion occurs when glandular cells develop on the outside of the cervix. Many individuals with cervical ectropion do not experience symptoms.
However, the primary symptom of cervical ectropion is a red, inflamed patch at the neck of the cervix.
The transformation zone appears this way because the glandular cells are delicate and irritate easily.
Other symptoms a woman may experience include:
pain and bleeding during or after sex
pain during or after cervical screening
light discharge of mucus
spotting between periods
Symptoms may range from mild to severe when they appear.

This patient has normal pap smear and is unlikely to have cervical cancer. She has no fever and vaginal discharge which would be the presentation of Chlamydia infection.

Endometrial cancer affects mainly post menopausal women and presents with vaginal bleeding, weight loss, dysuria and dyspareunia.

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 woman who is 26 weeks pregnant, has come in contact with a child having chickenpox 48 hours ago. As her IgG antibodies were negative during prenatal testing, she has no immunity against Varicella which makes her susceptible to get chickenpox.

Prophylactic treatment is required if a susceptible pregnant woman is exposed to chickenpox, which includes administration of varicella zoster immune globulin (VZIG), within 72 hours of exposure to infection.

As the patient has already checked for and was found to be negative, checking IgG level again is not relevant. Also, it was already revealed that she is not vaccinated against varicella before pregnancy.

If the patient had any symptoms typical of chickenpox, measuring IgM would have been helpful, but patient is completely asymptomatic in this case so measuring IgM is not indicated.

Vaccine for chickenpox is contraindicated during pregnancy as it is a live vaccine.

Activation of Antithrombin III and inactivation of factor Xa is the primary mechanism of action of Heparin.

Twin gestations are at increased risk for postpartum haemorrhage (PPH). A number of maternal and peripartum factors are associated with PPH requiring blood transfusion in twin gestations. Reducing the rate of caesarean delivery in twin pregnancies may decrease maternal hemorrhagic morbidity.

The progestogen-only pill (POP) is a contraceptive option for women who have high blood pressure either induced by use of combined oral pills or due to other causes; as long as it is well controlled and monitored. Combined oral contraception (COC) and Depo-Provera have been implicated in increased cardiovascular risk following use. High blood pressure has been theorized to be the critical path that leads to this increased risk. POP is the recommended method for women who are at risk of coronary heart disease due to presence of risk factors like hypertension.

Stopping OCP will risk in the patient getting pregnant. Cessation of oestrogen usually reverses the blood pressure back to normal, Hence, all other options are incorrect.

Heparin is a large-sized molecule and does not cross the placenta; it can provide anticoagulation in the mother, however, has no effect on the baby. Heparin is the preferred anticoagulant therapy during pregnancy.
Moreover, the anticoagulant effect of heparin can be rapidly reversed by protamine sulphate.
Warfarin, a coumarin derivative, takes much longer to be reversed compared to heparin. This can be given to the mother between 13 and 36 weeks of pregnancy, however, should be avoided in the first trimester due to its teratogenic effects.
The anticoagulant effect of coumarin derivatives on the baby also takes longer to be reversed.

Cord entanglement, a condition unique to MoMo pregnancies, occurs in 42 to 80% of the cases and it has been traditionally related to high perinatal mortality. Umbilical cord entanglement is present in all monoamniotic twins when it is systematically evaluated by ultrasound and colour Doppler. Perinatal mortality in monoamniotic twins is mainly a consequence of conjoined twins, twin reversed arterial perfusion (TRAP), discordant anomaly and spontaneous miscarriage before 20 weeks’ gestation. Expectantly managed monoamniotic twins after 20 weeks have a very good prognosis despite the finding of cord entanglement. The practice of elective very preterm delivery or other interventions to prevent cord accidents in monoamniotic twins should be re-evaluated.

This patient has got thrush or a fungal infection in the vaginal area. Candida infection is most likely based on the white discharge and itching. A vaginal clotrimazole antifungal treatment is required.

Adenomyosis or dysfunctional uterine haemorrhage are the most likely causes of heavy periods.
Because she refuses to have a hysterectomy or endometrial ablation, hormonal therapy must be administered in addition to the iron therapy she is already receiving.
Any of the choices could be employed, but using therapy only during the luteal phase of the cycle in someone who is virtually surely ovulating (based on her typical monthly cycles) is unlikely to work.

Danazol is prone to cause serious adverse effects (virilization), especially when used for a long period of time.
GnRH agonists would cause amenorrhoea but are more likely to cause substantial menopausal symptoms, and the °fa contraceptive pill (OCP) is generally best avoided in someone using hypertension medication.

Treatment with norethisterone throughout the cycle is likely to be the most successful of the treatments available.
If a levonorgestrel-releasing intrauterine device (Mirena®) had been offered as an alternative, it would have been acceptable.

The external carotid develops from the 1st arch. The common and internal carotid develop from the 3rd arch.

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

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.

The embryonic pole becomes visible on transvaginal ultrasound at around 5 and a half to 6 weeks gestation when it measures around 3mm.

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 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.

Oxytocin stimulates the myoepithelial cells in the breast causing the milk production. It also helps augment contractions in labour and cause uterine involution after childbirth.

Tubal sterilization is a safe and effective surgical procedure that permanently prevents pregnancy. However, pregnancy can occur in 1 in 200 cases, according to international sources. In the 1st year after tubal sterilization, the estimated failure rate is 0.1-0.8% respectively.

Normal closure of the ductus arteriosus (DA) is brought about by a number of mechanisms. Upon delivery the new born babies first breath inflates the lungs and this causes a rise in pO2. Oxygen is known to cause constriction of the DA in vivo and in vitro. In addition the decreased vascular resistance means the pressure within the lumen of the DA drops aiding closure. In addition on inflation of the lungs, the lungs produce bradykinin which stimulates smooth muscle constriction of the ductus. The most important factor is thought to be the drop in Prostaglandin E2. Prostaglandin E2 maintains patency of the Ductus in the unborn child but after birth is metabolised in the lungs and its levels fall rapidly within 3 hours of birth.

Tocolysis is an obstetrical procedure to prolong gestation in patients, some of which are experiencing preterm labour. This is achieved through various medications that work to inhibit contractions of uterine smooth muscle.

There is no definitive first-line tocolytic agent by the American College of Obstetrics and Gynecology (ACOG) but nifedipine is most commonly used. However, in severe aortic stenosis, nifedipine can cause ventricular collapse and dysfunction.

The therapeutic target in the treatment of preterm labour is currently the pharmacological inhibition of uterine contractions with the use of various tocolytic agents. Tocolytic agents are used to maintain pregnancy for 24–48 hours to allow corticosteroids administration to act and to permit the transfer of the mother to a centre with a neonatal intensive care unit.

Oxytocin inhibitors work by competitively acting at the oxytocin receptor site. Oxytocin acts to increase the intracellular levels of inositol triphosphate. The medications currently in this class are atosiban and retosiban. Maternal nor fetal side effects have not been described for this tocolytic.

The woman’s blood pressure was elevated at her visit; therefore she should be advised to immediately cease the oral contraceptive pill (OCP) so that the hypertension can resolve without the need for any hypotensive treatment. The blood pressure can then be reassessed in three months. Alternative, non-hormonal birth control methods such as condoms should be used instead.

If her high blood pressure does not resolve, any medication that would be commenced to reduce her blood pressure should be one that is safe to continue when she becomes pregnant.

It is inappropriate to continue the OCP even at a lower dosage or in combination with a hypotensive agent.

Methyldopa has been evaluated and used for treatment of hypertension during pregnancy. There is no clinical evidence to suggest that it causes harm to the foetus or neonate.

Angiotensin converting enzyme (ACE) inhibitors are not approved for use in pregnancy as they have been associated with fetal death in utero. Other antihypertensive agents such as beta-blockers and diuretics are also problematic in pregnancy and should be avoided.

Adolescents who fail to respond to first- or second-line treatment and have recurrent symptoms or have symptoms that worsen over time should be re-evaluated for other possible and serious causes of secondary dysmenorrhea such as endometriosis, uterine leiomyomas, polyps, or pelvic pathologies.

When pelvic pathology is suspected, abdominal and transvaginal ultrasonography should be used as first-line investigation. However, transvaginal ultrasound is more accurate and the preferred option if possible.

CT scan is not indicated in the assessment of dysmenorrhea.

D&C and laparoscopy can be considered as treatment options once a diagnosis has been established but can not be used as primary steps in diagnosis of dysmenorrhea.

Lymphatic vessels from the ovaries, joined by vessels from the uterine tubes and most from the fundus of the uterus, follow the ovarian veins as they ascend to the right and left lumbar (caval/aortic) lymph nodes.

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.

Consideration of the risk of scar rupture is probably the most important consideration when determining whether delivery should be by elective Caesarean section or by trial of vaginal delivery.
Most published studies do not differentiate between scar dehiscence and rupture, however, analysis of observational and comparative studies indicates that the excess risk of uterine rupture following trial of labour compared with women undergoing repeat elective Caesarean section is considerably lower than 1 per cent (25/10000); indeed, some studies do not demonstrate any increased risk.

Thyroid disease is the second most common endocrine disorder after diabetes in pregnancy. Thyroid disease poses a substantial challenge on the physiology of pregnant women and has significant maternal and fetal implications. Research shows during pregnancy, the size of the thyroid gland increases by 10% in countries with adequate iodine stores and by approximately 20% to 40% in countries with iodine deficiency. During pregnancy, thyroid hormone production increases by around 50% along with a similar increase in total daily iodine requirements.

The different changes occurring in thyroid physiology are as follow:
– An increase in serum thyroxine-binding globulin (TBG) leading to an increase in the total T4 and total T3 concentrations
– Stimulation of the thyrotropin (TSH) receptor by human chorionic gonadotropin (hCG) which increases thyroid hormone production and subsequently reduces serum TSH concentration.

Therefore, compared to the non-pregnant state, women tend to have lower serum TSH concentrations during pregnancy.
The need to adjust levothyroxine dose manifests itself as early as at 4-8 weeks of gestation, therefore justifying the adjustment of levothyroxine replacement to ensure that maternal euthyroidism is maintained during early gestation. Most of well-controlled hypothyroid pregnant women need increased dosage of thyroid hormone after pregnancy.

RNA viruses are almost always single stranded whilst DNA viruses are almost always double stranded. The exceptions are rotavirus and Parvovirus B19 respectively.