Continuous CTG produces a paper recording of the baby’s heart rate and the mother’s labour contractions. Although continuous CTG provides a written record, mothers cannot move freely during labour, change positions easily, or use a birthing pool to help with comfort and control during labour. It also means that some resources tend to be focused on the need to constantly interpret the CTG and not on the needs of a woman in labour.

Continuous CTG was associated with fewer fits for babies although there was no difference in cerebral palsy; both were rare events. However, continuous CTG was also associated with increased numbers of caesarean sections and instrumental births, both of which carry risks for mothers. Continuous CTG also makes moving and changing positions difficult in labour and women are unable to use a birthing pool. This can impact on women’s coping strategies. Women and their doctors need to discuss the woman’s individual needs and wishes about monitoring the baby’s wellbeing in labour.

Future research should focus on events that happen in pregnancy and labour that could be the cause of long term problems for the baby.

Above mentioned patient presented with symptoms of premature rupture of membranes (PROM) which refers to membrane rupture before the onset of uterine contractions.

A sudden gush of clear or pale yellow fluid from the vagina is the classic clinical presentation of premature rupture of membranes. Along with this the patient also developed signs of infection like fever, tachycardia and sweating which is suggestive of chorioamnionitis.

Vaginal examination is never performed in patients with premature rupture of membrane, instead a speculum examination is the usually preferred method which will show fluid in the posterior fornix.

The following are the steps in management of premature rupture of membrane:
– Admitting the patient to hospital.
– Take a vaginal
ervical smears.
– Measure and monitor both white cell count and C- reactive protein levels.
– Continue pregnancy if there is no evidence of infection or fetal distress.
– In presence of any signs of infection or if CTG showing fetal distress it is advisable to induce labour.
– Corticosteroids must be administered if delivery is prior to 34 weeks of gestation.
– Give antibiotics as prevention and for treatment of infection.

As the mother is found to be rhesus negative while her baby being rhesus positive, the given case is clinically diagnosed as spontaneous abortion due to Rh incompatibility. The mother should be administered anti-D for prophylaxis for avoiding future complications.

Rhesus (Rh) negative women who deliver a Rh-positive baby or who comes in contact with Rh positive red blood cells are at high risk for developing anti-Rh antibodies. The Rh positive fetuses
eonates of such mothers are at high risk of developing hemolytic disease of the fetus and newborn, which can be lethal or associated with serious morbidity.
In such situations both spontaneous and threatened abortion after 12 weeks of gestation, are indications to use anti-D in such situations.

All the other options are incorrect.

Breech presentation refers to the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first.

The current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned caesarean section for delivery sometime after 39 weeks.

This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes haemoglobin, haematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid- A peripheral smear and coagulation profiles also may be obtained- Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

→ Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
→ It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
→ Delivery is the definitive treatment for preeclampsia- The timing of delivery is determined by the gestational age of the foetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over caesarean delivery, if possible, in patients with preeclampsia.

As the time of onset of fever is the 4th day of postpartum and absence of uterine tenderness on exam makes infection of vaginal laceration the most likely cause of this presentation.

Exquisite uterine tenderness will be experienced in case of endometritis and symptoms are expected to start much earlier like by 2-3 days of postpartum.

UTI is often expected on days one or two of postpartum, also there are no urinary symptoms suggestive of UTI

Breast engorgement usually develops by 7th -2st day of postpartum and in the given case it’s too soon for it to occur.

As it is expected during the first 2 hours postpartum, Atelectasis is unlikely to be the cause of symptoms in the given case.

The commonest foetal presentation in twin pregnancy is cephalic-cephalic.

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

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

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

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

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

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

The next best line of management is immediate delivery via Caesarean section ( C section).

This is because of the change in cardiotocography (CTG). The pattern became much more severe with a virtual lack of short-term variability and prolonged decelerations. These changes indicate the necessity for an immediate C section as the cervix is not fully dilated.

As immediate delivery is indicated, another pH assessment is unnecessary as it would delay delivery and increase the likelihood of fetal hypoxia.

Delivery by ventose, in a primigravida where the cervix is only 8cm dilated is not indicated as it would allow the labour to proceed or augmenting with Syntocinon.

Pulmonary embolism (PE) is a treatable disease caused by thrombus formation in the lung-vasculature, commonly from the lower extremity’s deep veins compromising the blood flow to the lungs.
Computed tomography of pulmonary arteries (CTPA) and ventilation-perfusion (V/Q) scan are the two most common and widely practiced testing modalities to diagnose pulmonary embolism.

Pulmonary ventilation (V) and Perfusion (Q) scan, also known as lung V/Q scan, is a nuclear test that uses the perfusion scan to delineate the blood flow distribution and ventilation scan to measure airflow distribution in the lungs. The primary utilization of the V/Q scan is to help diagnose lung clots called pulmonary embolism. V/Q scan provides help in clinical decision-making by evaluating scans showing ventilation and perfusion in all areas of the lungs using radioactive tracers.

Ventilation-perfusion V/Q scanning is mostly indicated for a patient population in whom CTPA is contraindicated (pregnancy, renal insufficiency CKD stage 4 or more, or severe contrast allergy) or relatively inconclusive.

Preeclampsia prevention
Preeclampsia is defined as a new-onset hypertension along with other features like proteinuria &/or end-organ damage at >20 weeks of gestation.
Patients with the following histories are at high risk for preeclampsia:
– Those with prior history of preeclampsia
– Those with chronic kidney disease
– Those with chronic hypertension
– Those with diabetes mellitus
– Multiple gestation
– Autoimmune disease
Patients belonging in the following criteria are at moderate risk for preeclampsia:
– Obesity
– Advanced maternal age
– Nulliparity

Preeclampsia is considered as the leading cause for maternal and fetal morbidity and mortality. This is due to its increased risk for complications such as stroke, placental abruption and disseminated intravascular coagulation. It is most likely caused due to abnormal vasoconstriction and increased platelet aggregation, which thereby results in placental infarction and ischemia. The condition can be effectively prevented by the administration of low-doses of aspirin at 12 weeks of gestation.

Patients with predisposing factors, such as chronic kidney disease, chronic hypertension and a history of preeclampsia, particularly with severe features or at <37 weeks gestation as in this patient, are at higher risk for developing preeclampsia.
In high risk patients, the only therapy proven to decrease the risk of preeclampsia is a daily administration of low-dose aspirin, as it inhibits platelet aggregation and helps in preventing placental ischemia. Treatment is initiated at 12 – 28 weeks of gestation, optimally before 16 weeks and is continued till delivery.

Betamethasone is a drug used to accelerate fetal lung maturity in patients who are prone to imminent risk of preterm delivery before 37 weeks of gestation. In this case, if the patient develops pre-eclampsia requiring an urgent preterm delivery betamethasone will be indicated.

High-doses (4 mg) of folic acid is indicated in patients with high risk for a fetus with neural tube defects, as in those who have a history of any prior pregnancies affected or those patients who use any folate antagonist medications. In the given case patient is at average risk and requires only a regular dose of 0.4 mg which is found in most prenatal vitamins.

Intramuscular hydroxyprogesterone is indicated in pregnant patients with prior spontaneous preterm delivery due to preterm prelabor rupture of membranes, preterm labor, etc to decrease the possible risk for any recurrence. In patients who underwent preterm delivery due to other indications like preeclampsia with severe features, fetal growth restriction, etc it is not indicated.

Vaginal progesterone is administered to decrease the risk of preterm delivery in patients diagnosed with a shortened cervix, which is usually identified incidentally on anatomy ultrasound scan done between 16 and 24 weeks of gestation. This patient is currently at her 14 weeks, so this is not advisable.

Patients at high risk for pre-eclampsia, like those with preeclampsia in a prior pregnancy, are advised to start taking a daily low-dose aspirin as prophylaxis for prevention of pre-eclampsia during pregnancy.

First stage of the labour starts with the contractions of the uterus. With time, the no. of contractions, its duration and intensity increases. It ends once the cervix is fully dilated.

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. The intermittent vaginal bleeding and the requirement for manual removal of the placenta suggest endometritis as the most possible diagnosis.

Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.

Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.

Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.

Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.

Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.

The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labour soon. They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.

The best next line of management is to administer an oxytocic (Syntocinon) infusion.

This is because the progress of labour is slow, and it necessary to augment it. As the membranes have already ruptured, the next step is to increase the contractions and induce labour using an infusion of oxytocic (Syntocinon) infusion.

Extra fluid is also required, but this will be administered alongside the Syntocinon infusion.

A lumbar epidural block is indicated in patients with an occipito-posterior (OP) position. This should not be attempted until more pain relief is required and the progress of labour is reassessed.

A Caesarean section may be necessary due to obstructed labour or fetal distress, it is not indicated at this stage.

Taking blood and holding it in case cross-matching is ultimately required is common, but most patients do not have blood cross-matched prophylactically in case there is a need to be delivered by Caesarean section and require a transfusion.

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.

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.

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.

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.

There are a few differential diagnoses to think of in a patient that presents such as this one. Pre-eclampsia, cholecystitis, and fatty liver could all cause pain and tenderness, but cholecystitis would not normally cause the hypertension and proteinuria seen in this patient and neither would acute fatty liver of pregnancy. The more likely explanation is pre-eclampsia which must always be considered in the presence of these symptoms and signs. This process is particularly severe in the presence of pain and tenderness under the right costal margin due to liver capsule distension.

Chronic renal disease could cause the hypertension and mild proteinuria seen, but it would not usually produce the pain and tenderness that this patient has unless it was complicated by severe pre-eclampsia.

Biliary cholestasis does not usually produce pain.

This patient should be given promethazine and codeine as she presents with severe migraine.

Usage of metoclopramide is safe during pregnancy and for increasing effectiveness it can be added to paracetamol. However, because of its risk for causing extrapyramidal effects it should be used only as a second-line therapy and Promethazine should be considered as the first line choice of remedy. So the answer is Codeine and promethazine.

Opioid pain relievers such as codeine are not been reported of having any associated with increased birth defects or miscarriage, but its long-term use can lead to dependency in mother and withdrawal signs in the baby.

Paracetamol alone or combined with codeine is not found to be useful in controlling vomiting.

It is advised to completely avoid dihydroergotamine and the triptans throughout pregnancy.

A well contracted uterus excludes an atonic uterus. Delivery of large baby by a primigravida can cause cervical +/- vaginal tears which can lead to PPH.

Fetal lie refers to the relationship between the long axis of the foetus relative to the long axis of the mother. If the foetus and maternal column are parallel (on the same long axis), the lie is termed vertical or longitudinal lie.

Fetal presentation means, the part of the foetus which is overlying the maternal pelvic inlet.

Position is the positioning of the body of a prenatal foetus in the uterus. It will change as the foetus develops. This is a description of the relation of the presenting part of the foetus to the maternal pelvis. In the case of a longitudinal lie with a vertex presentation, the occiput of the fetal calvarium is the landmark used to describe the position. When the occiput is facing the maternal pubic symphysis, the position is termed direct occiput anterior.

Fetal attitude is defined as the relation of the various parts of the foetus to each other. In the normal attitude, the foetus is in universal flexion. The anatomic explanation for this posture is that it enables the foetus to occupy the least amount of space in the intrauterine cavity. The fetal attitude is extremely difficult, if not impossible, to assess without the help of an ultrasound examination.

Group B Streptococcus (GBS) or Streptococcus agalactiae is a Gram-positive bacteria which colonizes the gastrointestinal and genitourinary tract. In the United States of America, GBS is known to be the most common infectious cause of morbidity and mortality in neonates. GBS is known to cause both early onset and late onset infections in neonates, but current interventions are only effective in the prevention of early-onset disease.

The main risk factor for early-onset GBS infection is colonization of the maternal genital tract with Group B Streptococcus during labour. GBS is a normal flora of the gastrointestinal (GI) tract, which is thought to be the main source for maternal colonization.

The principal route of neonatal early onset GBS infection is vertical transmission from colonized mothers during passage through the vagina during labour and delivery.

Intravenous penicillin G is the treatment of choice for intrapartum antibiotic prophylaxis against Group B Streptococcus.

No adverse reactions in breastfed infants have been reported from maternal warfarin use during lactation, even with a dose of 25 mg daily for 7 days. There is a consensus that maternal warfarin therapy during breastfeeding poses little risk to the breastfed infant.

Common Risk factors for Ovarian torsion are presence of an ovarian mass, women who are in their reproductive age and history of infertility treatment with ovulation induction.
Common clinical presentations include sudden onset of unilateral pelvic pain along with nausea & vomiting and presence of a palpable adnexal mass. An adnexal mass with absent Doppler flow to ovary can be noted in ultrasound.
Laparoscopy with detorsion, ovarian cystectomy and oophorectomy if necrosis or malignancy is found are the common treatment options.

Acute lower abdominal pain in a nonpregnant women can have various causes including pathologies of the gastrointestinal, gynecologic, or urologic systems due to the close proximity of these structures. All of these cases have classic presentations which help to characterize the disease process and thereby to differentiate the diagnosis.

In the given case, patient presents with right lower quadrant pain which is classic for ovarian torsion, occurring due to rotation of the ovary around the infundibulopelvic ligament, causing ovarian vessel occlusion.  Although ovarian torsion can occur in any women in their reproductive-age, is seen more commonly in those with a history of ovarian cysts (eg, hemorrhagic cyst) or masses (eg, mature cystic teratoma) because of the greater size and density of the ovary which makes it prone to rotation and subsequent torsion. Patients will initially have intermittent pain associated with activity, as in this patient, due to partial ovarian torsion, this initial pain resolves when the adnexa spontaneously untwists and blood flow returns. When this progresses to complete ovarian torsion, patients typically develop sudden-onset, severe, nonradiating pain due to persistent ischemia, which is often associated with nausea and vomiting.

Ovarian torsion can be clinically diagnosed, but a Doppler ultrasound is performed to evaluate ovarian blood flow and also to confirm the diagnosis. Surgical detorsion to prevent ovarian necrosis and cystectomy/oophorectomy are the usual treatment options.

Any association of urinary symptoms will help to establish a urologic cause of acute right lower quadrant pain like pyelonephritis, nephrolithiasis, etc.  However, patients with urologic conditions typically presents with suprapubic or flank pain which radiates to the right lower quadrant, making this diagnosis less likely in the given case.

A family history of malignancy usually does not aid in the diagnosis of acute lower abdominal pain. Although some ovarian cancers are inherited, patients with ovarian cancer typically have a chronic, indolent course with associated weight loss, early satiety, and abdominal distension.

Having multiple sexual partners is considered a risk factor for sexually transmitted infections and pelvic inflammatory disease, which can be a cause for lower abdominal pain. However, patients will typically have fever, constant and diffused pelvic pain along with rebound and guarding.

Recent sick contacts are a risk factor for gastroenteritis, which can present with nausea, vomiting and abdominal pain. However, in this case patient will typically have diffuse, cramping abdominal pain which will worsen gradually; along with persistent vomiting and diarrhea.

Ovarian torsion typically causes intermittent lower abdominal pain followed by sudden-onset of severe, nonradiating unilateral pain with associated nausea and vomiting. Ovarian torsion can occur in women in their reproductive-age, particularly those with a history of ovarian cysts.

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.

A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.

The NICE guidelines on Hypertension in pregnancy define blood pressure in pregnancy as follows:
Mild hypertension: DBP=90-99 mmHg, SBP=140-149 mmHg. Moderate hypertension: DBP=100-109 mmHg, SBP=150-159 mmHg.
Severe hypertension: DBP=110 mmHg or greater, SBP=160 mmHg or greater.

This pregnant woman likely has an infection with the rubella virus, which increases the risk of congenital rubella syndrome in her newborn. congenital heart diseases, particularly patent ductus arteriosus (PDA) is a part of this syndrome. Persistence of a patent vessel between the left pulmonary artery and aorta which is supposed to closes in the first 18 hours functionally and in the first 2–3 days of life anatomically is called as PDA.

Normally there is right to left shunting in utero, but in case of PDA blood is shunted from the left (aorta) to the right (pulmonary artery) due to the decrease in pulmonary vascular resistance after birth. This causes right ventricular hypertrophy, if left untreated it can lead to left ventricular hypertrophy and heart failure. There will be a continuous machine-like murmur, heard over the left upper sternal border, as the blood is shunted throughout cardiac cycle. Diastolic BP becomes lower than normal, leading to a higher pulse pressure which is felt as a bounding pulse due to the lost volume from aorta. Though PDA is a non-cyanotic condition, it may lead to Eisenmenger’s syndrome in which R to L shunting persists, resulting in cyanosis, clubbing and polycythemia. Treatment with nonsteroidal anti-inflammatory drugs like indomethacin can close patent PDA. Other symptoms in infants born with rubella syndrome are microcephaly and cataract.

The characteristic feature of an atrial septal defect or ASD, which is a congenital heart disease presenting as an opening in the septa between right and left atria, is a single fixed S2. There will be a delay in closure of the pulmonic valve, due to the excess amount of blood diverted to the right side.

Brachial-femoral delay is a finding in coarctation of aorta, which presents as hypertension in the upper extremities and hypotension in the lower extremities.

A double split S2 is a physiological finding caused by the closure of pulmonary and aortic valves on inspiration.

PDA and pulmonary artery stenosis are the most common cardiac defects reported along with congenital rubella syndrome (CRS), whereas tricuspid valve regurgitation is never reported along with it.

Learning objective: is associated with a continuous machine-like murmur heard over the left upper sternal border, bounding pulse and an increased pulse pressure are the usual symptoms associated with patent ductus arteriosus (PDA), which is mostly seen along with congenital rubella syndrome.

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.

Mediolateral episiotomy is favoured to midline episiotomy because there is less extension of the incision and decreased chances of injury to the anal sphincter and rectum.

Endometriosis is a chronic gynaecologic disease characterized by the development and presence of histological elements like endometrial glands and stroma in anatomical positions and organs outside of the uterine cavity. The main clinical manifestations of the disease are chronic pelvic pain and impaired fertility. The localization of endometriosis lesions can vary, with the most commonly involved focus of the disease the ovaries followed by the posterior broad ligament, the anterior cul-de-sac, the posterior cul-de-sac, and the uterosacral ligament.

The clinical presentation of the disease differs in women and may be unexpected not only in the presentation but also in the duration. Clinicians usually suspect and are more likely to diagnose the disease in females presenting with the typical symptomatology such as dyspareunia, namely painful sexual intercourse, pelvic pain during menstruation (dysmenorrhea), pain in the urination (dysuria), defecation (dyschezia), and/or infertility. The pain is usually characterized as chronic, cyclic, and progressive (exacerbating over time). Furthermore, some women suffering from endometriosis experience hyperalgesia, a phenomenon, when even with the application of a nonpainful stimulus, an intolerable painful reaction is released. This condition indicates neuropathic pain.

Tenderness on vaginal examination, palpable nodules in the posterior fornix, adnexal masses, and immobility of the uterus are diagnostically indicating findings of endometriosis.

Pregnancy is considered as a hypercoagulable state with an increased risk for the development of conditions like deep venous thrombosis (DVT) and pulmonary embolism (PE). Among these two PE is the considered the most significant cause for maternal death in Australia.
A pregnant women with venous thromboembolism should be treated with heparin as warfarin is contraindicated. Warfarin should be avoided throughout pregnancy and especially during the first and third trimesters of pregnancy as it crosses the placenta. Intake of warfarin at 6-12 weeks of pregnancy can results in fetal warfarin syndrome which is characterised by:
– A characteristic nasal hypoplasia
– Short fingers with hypoplastic nails
– Calcified epiphyses, namely chondrodysplasia punctuta which is evident by stippling of epiphyses on X-ray.
– Intellectual disability
– Low birth weight
Recent studies show that the risk of fetal warfarin syndrome is around 5 % more in babies of women who require warfarin throughout pregnancy and the risk is always dose dependent.
Later exposure to warfarin, as in after 12 weeks, is mostly associated with central nervous system anomalies like microcephaly, hydrocephalus, agenesis of corpus callosum, Dandy-Walker malformation which is characterised by complete absence of cerebellar vermis along with enlarged fourth ventricle and mental retardation. Eye anomalies such as optic atrophy, microphthalmia, and Peter anomaly which is the dysgenesis of the anterior segment are also found in association. Newborns exposed to warfarin in all three trimesters are prone to present with blindness. Other complications found in neonates exposed to warfarin are perinatal intracranial hemorrhage and other major bleeding episodes.

Warfarin is not secreted into the breast milk and is so safe to use during the postpartum period.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication for suppression of labour.
Suppression of labour known as tocolysis is contraindicated in situations like suspected foetal compromise, which is diagnosed by cardiotocograph warranting delivery, in cases of placental abruption, in chorioamnionitis, in severe pre-eclampsia, cases were gestational age is more than 34 weeks, in cases of foetal death in utero and in cases where palliative care is planned due to foetal malformations.

The best method to provide symptomatic relief to this woman is to use pressure stockings and a vulval pad (correct answer). This will provide relief without causing any adverse effects.

In order to prevent ulceration, care is required to avoid trauma.

Since the patient is pregnant, surgical ligation or injecting of sclerosing solutions cannot be considered and are contraindicated.

Development of varices is often exacerbated in subsequent pregnancies; and therefore surgery should be eschewed until child-bearing is complete,

Bed rest in hospital would reduce the symptoms of the varicose veins; however this should be avoided as it can increase the risk of developing deep vein thrombosis.

Anticoagulant therapy has not been shown to be beneficial for treatment of varicosities that only affect the superficial venous system and should therefore not be used.

The case above gives a classic presentation of preterm premature rupture of membranes(PPROM). In term or near term women rupture of membrane harbingers labor, so if ROM does not end up in established labor in 4 hours, is called as premature ROM (PROM). In other words, PROM is defined as ROM before the onset of labor and if it occurs before 37 weeks, the preferred term is PPROM. In both these scenarios treatment approach will be different.
A sudden gush of watery fluid per vagina, continuous or intermittent leakage of fluid, a sensation of wetness within the vagina or perineum are the classic presentation of rupture of the membranes(ROM), regardless of the gestational age. Pathognomonic symptoms symptoms of ROM are presence of liquor flowing from the cervical os or pooling in the posterior vaginal fornix.
PPROM is associated with many risk factors and some of them are as follows:
– Preterm labor
– Cord prolapse
– Placental abruption
– Chorioamnionitis
– Fetal pulmonary hypoplasia and other features of prematurity
– Limb positioning defects
– Perinatal mortality
Once the diagnosis is confirmed the following measures should be considered in the management plan:
a) Maternal corticosteroids
Adverse perinatal outcomes like respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis can be effectively reduced using corticosteroids. The duration of using neonatal respiratory support, in case of respiratory distress, can be significantly reduced by the administration of corticosteroids. If preterm labor is a concern in cases were gestational age is between 23•0d and 34•6d weeks or if preterm birth is planned or expected within the next 7 days corticosteroids are indicated.
Recommended regimens to the woman are IM betamethasone in two doses of 11.4 mg, given 24 hours apart and if betamethasone is unavailable, IM dexamethasone given 24 hours apart in two doses of 12 mg.
A single repeat dose of corticosteroid given seven days or more after the first dose is suggestive in cases were the gestational age is less than 32• 6d, if the woman is still considered to be at risk of preterm labor, up to 3 repeated doses can be considered.
Another option is Tocolysis using nifedipine and is indicated if the woman is in labor. This helps in cessation of labor for at least 48 hours, providing a window for corticosteroid to establish its effects. Tocolysis is not indicated in cases with absence of uterine contractions suggestive of labor.
It is appropriate to transfer this woman to a tertiary hospital after administering the first doses of corticosteroid and antibiotics. This ensures optimal neonatal care in case of premature delivery.
As the patient needs investigations and fetal monitoring along with close observation for development of any signs of infection and preterm labor, it is not appropriate to discharge this patient on oral antibiotics
Admitting to a primary care center without neonatal ICU (NICU) does no good to the outcome of this patient.

The most suitable step would be to wait for spontaneous onset of labour. This woman would be able to deliver vaginally in 3 situations. The first would be if the foetus is estimated to weigh less than 3800g (first child weight 3800g). Another would be if the foetus is in a frank or complete breech presentation and lastly if the rate of labour progress is satisfactory and breech extraction is unnecessary. RCOG (Royal College of Obstetricians & Gynaecologists) guidelines recommends that women should be informed that elective Caesarean section for the delivery of a breech baby would have a lower risk of perinatal mortality than a planned vaginal delivery. This is because with an elective Caesarean section, we would be able to avoid stillbirth following 39 weeks of gestation as well as intrapartum and vaginal breech delivery risks. The ideal mode of delivery of a breech foetus when labour starts or at least close to term is a Caesarean section as the risks towards the foetus would be significantly increased in a vaginal delivery. The obstetrician is responsible to ensure that there are no other abnormalities that could complicate this even further such as footling presentation, low estimated birth weight (less than 10th centile), hyperextended neck on ultrasound, evidence of fetal distress and high estimated birth weight (>3.8kg). Provided that there is a normal progression of events, fetal risks during both labour and delivery should be low if such factors are absent. Hence, it is right to await the onset of labour to occur spontaneously in this case. In order to exclude a knee presentation with fetal head extension or a footling breech, ultrasound examination has to be done. These are linked to a high fetal risk if the mother attempts vaginal delivery. X-ray pelvimetry is advisable but is not essential in fetal size assessment since its accuracy is roughly 20%. In this case, it is not indicated since there is evidence that her pelvis is of adequate size as she had already delivered a 3.9kg baby prior. It is best to avoid induction of labour in breech cases for numerous reasons (need for augmentation, cord prolapse).

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

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

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

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.

This patient presents because of significant mood changes since she gave birth to her child: she is sad most of times and she is having guilt feelings about her adequacy for motherhood- She is also complaining of insomnia, tiredness, and even some suicidal ideation. These symptoms are highly suggestive postpartum depression. This should be differentiated from postpartum blues, which usually present within the first 2 weeks and last for few days. This patient’s symptoms started 5 weeks postpartum. Postpartum depression usually presents within the first 6 weeks to the first year postpartum.

Postpartum depression is the most common complication of childbearing and affects the mother, the child, and relationship with the partner. It is diagnosed the same way as major depressive disorder in other patients. Since untreated postpartum depression can have long-term effects on the mother and the child, appropriate therapy should be undertaken as soon as possible- Antidepressant medications such as sertraline can be used to treat postpartum depression. In a patient who has suicidal ideation, electroconvulsive therapy has a more rapid and effective action than medication and should be considered in these patients.

→ Cognitive behavioural therapy is effective in women with mild to moderate postpartum depression; it would not be a good choice in this patient with suicidal ideation and at risk of harming the baby.
→ Estrogen therapy used alone or in combination with antidepressant, has been shown to significantly reduce the symptoms of postpartum depression; however, it would not be the most appropriate choice in a patient with suicidal ideation.
→ Peer support has shown equivocal results in various studies even though most postpartum patients report that lacking an intimate friend or confidant or facing social isolation are factors leading to depression.
→ Non-directive counselling also known as ”listening visits“ has been found to be effective in postpartum patients, though the studies that were conducted are deemed to be of small sample and larger studies still need to be done to validate these findings. It would not be an appropriate choice for this patient with suicidal ideation.

The drug of choice for eclampsia and pre-eclampsia is magnesium sulphate. It is given as a loading dose of 4g i/v over 5 minutes, followed by an infusion for the next 24 hours at the rate of 1g/hr. If the seizures are not controlled, an additional dose of MgSO4 2-4gm i/v can be given over five minutes. Patients with eclampsia or pre-eclampsia can develop any of the following symptoms: persistent headache, visual abnormalities like photophobia, blurring of vison or temporary blindness, epigastric pain, dyspnoea and altered mental status.

Counselling her about the risks associated with obesity during pregnancy will be the best possible advice to give this patient. A combined follow up by an obstetrician and a diabetes specialist at a high-risk pregnancy clinic is required to formulate the best ways in management of gestation with obesity.
An oral glucose tolerance test should be done at 26 weeks of her pregnancy, along with advising her on controlling her weight by diet and lifestyle modifications. During the early weeks of their pregnancy all obese patients must be routinely tested for pre-existing diabetes.

It is highly inappropriate to advice her not to get pregnant.

Without making a proper diagnosis of diabetes, it is wrong to ask her to start oral hypoglycemic agent and/or insulin.

Checking urinary proteins is not indicated at this stage, but can be considered as a part of antenatal check up.

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.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

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.

Paracetamol is safe to take during pregnancy and has shown no harm to unborn children during studies. It is the treatment of choice for mild to moderate pain during pregnancy.

This patient is towards the end of the first stage of labour and is having complications. Labour is divided into 3 stages. The first stage begins at regular uterine contractions and ends with complete cervical dilatation at 10 cm. It has a latent phase and an active phase- The active phase is usually considered to have begun when cervical dilatation reaches 4 cm. So this patient is in the active phase of the first stag- The second stage begins with complete cervical dilatation and ends with the delivery of the foetus. The third stage of labour is the period between the delivery of the foetus and the delivery of the placenta and fetal membranes.

This patient’s contractions seem adequate and yet the fetal heart tone with baseline 80/min and absent variability suggests fetal distress. This is category III of the fetal heart rate pattern because the baseline rate is < 110/min with absent variability. It is usually predictive of abnormal acid-base status. The recommended actions are maternal position change and oxygen administration, discontinuation of labour stimulus such as oxytocin, treatment of possible underlying conditions, and expedited delivery.
→ Magnesium sulphate infusion is mainly used to prevent eclamptic seizures and despite no evidence of its effectiveness as a tocolytic agent, it is used sometimes to reduce risks of preterm birth.
→ Fetal scalp pH monitoring would help determine if there is indeed an acidosis and should be done before deciding whether a Caesarean section is necessary, but maternal position change and oxygen administration should be done first.
→ Ultrasonography may be used for preinduction cervical length measurement or if the active stage has already started- It is considered more accurate than digital pelvic exam in the assessment of fetal descent; however, at this point maternal position change and oxygen administration should be done first.
→ Immediate Caesarean section would be done if fetal scalp pH monitoring revealed a pH < 7.20. At this point, the best next step is maternal position change and oxygen administration.

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.

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

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.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

As they respond differently to different drugs, a thorough distinguishing must be done between the two major groups of epilepsies while approaching a woman, who wishes to become pregnant while on antiepileptic drugs.

Partial epilepsies will respond to most of the antiepileptic drugs, but in case of idiopathic generalized epilepsies, especially in juvenile myoclonic epilepsy, seizure can be controlled only with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful but substitution of sodium valproate with lamotrigine is not the right choice. This is because lamotrigine is not as effective as sodium valproate and will sometimes worsens myoclonic seizures in juvenile myoclonic epilepsy.

Topiramate and levetiracetam are found to be effective in idiopathic generalized epilepsy, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially in myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there will be no effective alternative to sodium valproate as cessation of sodium valproate will lead to recurrence of the generalized seizures, especially juvenile myoclonic epilepsy. Hence, it is not advisable to discontinue the drug in auch patients.

On the other hand, sodium valproate have the highest reported teratogenicity potential among antiepileptic drugs and the Australian Pregnancy Register has reported the risk to be as high as 16% if used in first trimester. Sodium valproate should be avoided in women of reproductive age and if a patient on the medication is willing to become pregnant, she should be well informed about the risk of teratogenicity and the decision must be left to her. If she decides to accept the risks and continue with pregnancy, the lowest possible effective dose should be prescribed to her.

If the dose of sodium valproate has been reduced to minimum during pregnancy to reduce the possible teratogenesis, it is recommended to re-establish the prepartum effective dose before the onset of labor. This is because, it is the time with increased risk for seizures, especially in patients with idiopathic generalised epilepsy who are very sensitive to sleep deprivation. Valproate therapy is found to be safe during breastfeeding.

This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

Caesarean section is rarely needed to be done when the foetus is already dead.

Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

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.

Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid.

Neural tube defects (NTD) were 43% more common in Indigenous than in non-Indigenous infants in Western Australia in the 1980s, and there has been a fall in NTD overall in Western Australia since promotion of folate and voluntary fortification of food has occurred.

Women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

Women planning pregnancy might be exposed to medications with known antifolate activities affecting different parts of the folic acid metabolic cascade. A relatively large number of epidemiologic studies have shown an increased risk of NTDs among babies exposed in early gestation to antiepileptic drugs (carbamazepine, valproate, barbiturates), sulphonamides, or methotrexate. Hence, whenever women use these medications, or have used them near conception, they should take 5 mg/d of folic acid until the end of the first trimester of pregnancy.

In this case, induction of labour at 37 weeks of gestation was necessary due to the absence of spontaneous of labour 24 hours after rupture of membranes. High doses of Syntocin and large volume of fluids may be required particularly when induction is done before term.

Syntocin infusion can lead to uterine hypertonus and tetany which can result in fetal distress at any dosage. This is a common reason to decrease or stop the infusion and an indication for Caesarean delivery due to fetal distress

Uterine rupture can occur as a result of Syntocin infusion especially when the accompanying fluids do not contain electrolytes, which puts the patient at risk for water intoxication.

Maternal hypotension results from Syntocin infusion, not hypertension.

This patient presenting with oligohydramnios in her third trimester and had reported an episode of sudden gush of fluid secondary to ruptured membrane which she had mistaken to be “urinary incontinence”.  Hence, the most likely cause of oligohydramnios in this patient will be premature preterm rupture of membrane (PPROM).

An amniotic fluid volume which is less than expected for gestational age is called as Oligohydramnios and is typically diagnosed by ultrasound examination. This condition can be qualitatively described as reduced amniotic fluid volume and quantitatively as amniotic fluid index ≤5 cm or a single deepest pocket <2 cm. Oligohydramnios either can be idiopathic or may have a maternal, fetal or placental cause. Fetal prognosis in this case depends on several factors like the underlying cause, the severity of loss ie. reduced versus no amniotic fluid state and the gestational age at which oligohydramnios occurred. As an adequate volume of amniotic fluid is critical for the normal fetal movements, for fetal lung development and for cushioning the fetus and umbilical cord from uterine compression, so pregnancies complicated with oligohydramnios are at higher risk for fetal deformation, pulmonary hypoplasia and umbilical cord compression.
Oligohydramnios is also associated with an increased risk for fetal or neonatal death, which can either be related to the underlying cause of reduction in amniotic fluid volume or due to the sequelae caused due to reduced amniotic fluid volume. The amniotic fluid volume reflects the balance between fluid production and movement of fluid out of the amniotic sac and the most common mechanisms behind oligohydramnios are fetal oliguria/anuria or fluid loss due to rupture of membranes; also reduction in the amount of lung fluid or increased swallowing do not play major roles in this. Idiopathic cases as in idiopathic oligohydramnios, may be due to alterations in the expression of water pores like aquaporin 1 and aquaporin 3, present in fetal membranes and placenta.

Causes of oligohydramnios
a) Maternal causes includes:
– Medical or obstetric conditions associated with uteroplacental insufficiency like preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia.
– Intake of medications like angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab.
b) Placental causes are:
– Abruption of placenta
– Twin polyhydramnios-oligohydramnios sequence which is the Twin to twin transfusion
– Placental thrombosis or infarction
c) Fetal cases leading to oligohydramnios are:
– Chromosomal abnormalities
– Congenital abnormalities which are associated with impaired urine production
– Growth restriction
– Demise
– Post-term pregnancy
– Ruptured fetal membranes
– Infections
– Idiopathic causes

During First trimester: Etiology of oligohydramnios during the first trimester is often unclear. As the gestational sac fluid is primarily derived from the fetal surface of the placenta via transamniotic flow from the maternal compartment and secretions from the surface of the body of the embryo reduced amniotic fluid prior to 10 weeks of gestation is rare.

During Second trimester: Fetal urine begins to enter the amniotic sac and fetus begins to swallow amniotic fluid by the beginning of second trimester, therefore, during this period any disorders related to the renal/urinary system of the fetus begins to play a prominent role in the etiology of oligohydramnios. Some of such anomalies include intrinsic renal disorders like cystic renal disease and obstructive lesions of the lower urinary tract like posterior urethral valves or urethral atresia. Other common causes of oligohydramnios in the second trimester are maternal and placental factors and traumatic or nontraumatic rupture of the fetal membranes.

During Third trimester: Oligohydramnios which is first diagnosed in the third trimester is often associated with PPROM or with conditions such as preeclampsia or other maternal vascular diseases leading to uteroplacental insufficiency. Oligohydramnios frequently accompanies fetal growth restriction as a result of uteroplacental insufficiency.

A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour

If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.

Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.

No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.

Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin.

This patient who is at her 29 weeks of pregnancy, presented with sudden gush of clear fluid and Speculum examination has confirmed premature rupture of membrane (PROM).

Approximately, 50% of PROM progress to labour within 24 hours and in the remaining, 80% within seven days. The most important next step of management in this case is transferring this patient to tertiary care hospital as soon as possible. It is equally important to give corticosteroid therapy, like Betamethasone, if delivery prior to 34 weeks is likely to occur, as it will help in fetal lung maturity.

Cardiotocography (CTG) is usually not available in general practice settings and it can be done only while in the hospital. If CTG shows any abnormality or if there is any presence of infection it is better to induce labor.

Salbutamol and nifedipine are of no use in this case, as the patient is not in labour and does not require tocolytics.

Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include post thrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation.

Low molecular weight heparin (LMWH) is the preferred agent for prophylaxis and treatment of DVT during pregnancy. A disadvantage of LMWH over unfractionated heparin (UFH) is its longer half-life, which may be a problem at the time of delivery.

The given case where the patient presents with sudden abdominal pain, cessation of uterine contraction and the urge to push along with vaginal bleeding is typical for uterine rupture. Examination shows a decreased or lost fetal heart rate, along with signs of fluid collection including fluid thrill and shifting dullness due to the entry of blood into the peritoneal cavity.
Other common manifestations of uterine rupture include:
– Loss of the station of the fetal presenting part
– Vaginal bleeding which is not be proportionate to the hemodynamic status
-Maternal tachycardia and hypotension ranging from subtle to severer shock
– Uterine tenderness
– Change in uterine shape and contour
– Easily palpable fetal parts
– No fetal presentation on vaginal examination
– Hematuria if the rupture extends to the bladder
Anterior lower transverse segment is the most common site of spontaneous uterine rupture.

Placenta previa usually presents as painless vaginal bleeding, which rules it out as the diagnosis in given case.

Vaginal bleeding with a tender and tense uterus is the presentation in placental abruption, also contrary to uterine rupture, uterine contractions will continue in case of placental abruption.

Cervical laceration can be a possibility, but in such cases more amount of vaginal blood loss was expected in this patient with hemodynamic instability. Also symptoms like deformed uterus, abdominal distention and cessation of contractions are inconsistent with cervical laceration.

Excessive generation of thrombin and fibrin in the circulating blood results in Disseminated intravascular coagulation (DIC) which leads to increased platelets aggregation and consumption of coagulation factors resulting in consequent bleeding at one site and thromboembolism at another. Placental abruption and retained products of conception in the uterine cavity are the most common obstetric causes of DIC. The condition will not fit as diagnosis in this clinical scenario.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

In this pregnant patient with an antepartum haemorrhage at 37 weeks of gestation, her clinical presentation points to a placenta previa. Her bleeding has stopped, the uterus is of the expected size and non-tender, and the fetal head is still mobile above the pelvic brim which are all findings that would be consistent with a placenta praevia. An ultrasound examination would be done to rule-out or diagnose the condition.

An Apt test on the blood is necessary to ensure that this is not fetal blood that would come from a ruptured vasa praevia. Although this diagnosis would be unlikely since the bleeding has stopped. If there was a vasa praevia, there would be fetal tachycardia or bradycardia, where a tachycardia is often seen first but then bradycardia takes over late as fetal exsanguination occurs.

In a placental abruption with concealment of blood loss, the uterus would be larger and some uterine tenderness would be found on exam.

A cervical polyp could bleed after sexual intercourse and a speculum examination would be done to exclude it. However, it would be unlikely for a cervical polyp to cause such a large amount of blood loss. A heavy show would also rarely have as heavy as a loss of 200mL.

Complete abortion is defined as a ‘complete’ passage of all conception products.

The first day of the last menstrual period and findings on any prior ultrasounds should be determined to establish the gestational age and location of the pregnancy. An abdominal exam should be performed to assess for peritoneal signs that might indicate a ruptured ectopic pregnancy or extra-uterine extension of a septic abortion. Lastly, a pelvic exam is central to the evaluation of suspected miscarriage. It should include both speculum-facilitated visualization of the cervix and a bimanual examination to assess for cervical motion tenderness that may indicate a septic abortion or an adnexal mass that may herald ectopic pregnancy.

Early pregnancy loss takes many different forms. In missed abortion, there is asymptomatic or ‘missed’ death of the embryo or foetus without sufficient uterine contractions to push out the products of conception. In contrast, threatened abortion is characterized by symptomatic, ‘threatened’ expulsion of the products of conception, yet the cervical os remains closed, and the embryo or foetus remains viable.

Although there is a lack of consensus, complete abortion is often defined as the absence of a gestational sac on ultrasound with an endometrial stripe thickness of less than 30 mm.

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.

CVS has decreased in frequency with the recent increased uptake of cell-free DNA screening. It remains the only diagnostic test available in the first trimester and allows for diagnostic analyses, including fluorescence in situ hybridization (FISH), karyotype, microarray, molecular testing, and gene sequencing. CVS is performed between 10 and 14 weeks’ gestation. CVS has been performed before 9 weeks in the past, though this has shown to increase the risk of limb deformities and, therefore, is no longer recommended.

If a pregnant woman develops primary herpes simplex infection after 30 weeks gestation, her risk for transmission of herpes simplex virus to the neonate leading to neonatal infection increases significantly.
Below mentioned are the most common risk factors resulting in intrapartum herpes simplex infection of the baby:
– Premature labor
– Premature rupture of membrane
-Primary herpes simplex infection near the time of delivery
– Multiple lesions in the genital area
The most appropriate management for such case includes:
– Checking for herpes simplex infection with PCR testing (cervical swab)
– Prophylactic antiviral therapy of the mother from 36th week until delivery
– Cesarean section delivery

In the case above mentioned, it is better to start antiviral therapy immediately and consider cesarean section to minimize the risk of vertical transmission of infection to the neonate.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

Antenatal screening for rubella IgG is a routine recommended for all pregnant women at their first visit. All pregnant women who have a history of contact with rubella or any clinical features consistent with rubella –like illness should be screened for the presence of rising antibody titre and / or rubella specific IgM. Serological confirmation is mandatory for diagnosing rubella.
As in this case scenario, positive lgM for rubella indicates active rubella infection, in such cases it is recommended to repeat the test. If lgM is still positive, it confirms rubella infection. No further testing from another laboratory is required.
The risk for fetal infection and damage is higher if rubella infection occurs during the first trimester of pregnancy, which is 85% in the first two months of pregnancy and 50 -80% in the third month. Therefore, termination of pregnancy is usually recommended in this situation. NHIG has been used in trials for prophylaxis and prevention of congenital rubella syndrome after contact to a case with rubella infection, but the results have been discouraging, therefore, it is not advisable.
In the given case, rubella infection has been established already, so NHIG will not be of any benefit as primary prevention.
Rubella-containing vaccines like MMR vaccine is a live attenuated vaccine are contraindicated throughout pregnancy, it should be avoided; and women who remain susceptible to rubella should receive MMR vaccine postpartum.
Risk of fetal infection and/or fetal damage or for development of congenital rubella syndrome is related to the timing of maternal infection. Cases with Primary infection is found to be in higher risk
In cases of asymptomatic re-infection with a good history of previous positive serology, even though it is difficult to quantify, the risk of fetal infection has been reported to be < 5 percent. Congenital rubella syndrome following maternal re-infection is considered rare particularly if re-infection occurs after 12 weeks. If the clinical picture is typically of rubella or if possibility of previous immunity is inconclusive based on serology, then the risk is assumed to be the same as that of primary infection.

The principal screening test for detecting maternal HBV infection is the serologic identification of HBsAg. Screening should be performed in each pregnancy, regardless of previous HBV vaccination or previous negative HBsAg test results.

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (e.g., injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Interventions to prevent perinatal transmission of HBV infection include screening all pregnant women for HBV, vaccinating infants born to HBV-negative mothers within 24 hours of birth, and completing the HBV vaccination series in infants by age 18 months.

Contraindications to tocolysis in preterm labor are as follows:
– Gestational age > 34 weeks or <24 weeks
– Labor is too advanced with an advanced cervical dilation of >4 cm
– Abnormal CTG suggesting a non-reassuring fetal status
– Lethal fetal anomalies
– Intrauterine fetal demise
– Suspected fetal compromise
– Significant antepartum hemorrhage, such as placental abruption/ active vaginal bleeding with hemodynamic instability
– Any suspected intrauterine infections like chorioamnionitis
– Maternal hypotension
– Pregnancy-induced hypertension/ eclampsia/ pre-eclampsia
– Placenta previa
– Placental insufficiency
– Intrauterine growth retardation
– Maternal allergy to specific tocolytic agents or cases where tocolytics are contraindicated due to specific comorbidities like in case of cardiac disease, were beta agonists cannot be administered.

As there are nonpulmonary morbidities associated with preterm birth, fetal pulmonary maturity, known or suspected, is not an absolute contraindication for tocolysis. These fetuses could potentially benefit from prolongation of pregnancy and from the nonpulmonary benefits of glucocorticoid therapy.

When cervical dilation is greater than 3 cm inhibition of preterm labor is less likely to be successful. In such cases Tocolysis can be considered when the goal is to administer antenatal corticosteroids or to safely transport the mother to a tertiary care center.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication to suppression of labor.

In the given case pre-pregnancy counselling and management of chronic hypertension is very much essential.
Some commonly prescribed antihypertensive drugs like ACE inhibitors, angiotensin receptor antagonists, diuretics and most beta blockers are contraindicated or is best to be avoided before conception and during pregnancy.
Methyldopa is considered as the first line drug for the management of mild to moderate hypertension in pregnancy and is the most commonly prescribed antihypertensive for this indication.
Hydralazine can be used during any hypertensive emergencies in pregnancy.
Intake of Angiotensin receptor blockers and ACE inhibitors during the first trimester can lead to complications as they are both teratogenic; use of these drugs during second and third trimesters can result in foetal renal dysfunction, oligohydramnios and skull hypoplasia.
Diuretics can cause foetal electrolyte disturbances and significant reduction in maternal blood volume.
All beta blockers, except labetalol, can result in foetal bradycardia, and growth restriction in case its long-term use.
Calcium channel antagonists, except nifedipine, are avoided during pregnancy due to its high risk for maternal hypotension and foetal hypoxia.

This patient with a previous history of pre-eclampsia and obesity is at high risk for developing pre-eclampsia.

A daily intake of 1000mg of calcium is observed to be helpful in reducing the incidence of any hypertensive disorders and preterm labour.

Vitamin A should always be avoided during pregnancy as it is fetotoxic.

All other options are incorrect.

Parvovirus B19 is a single-stranded DNA virus, which is the causative organism for erythema infectiosum, also known as fifth disease or slapped cheek syndrome.

Maternal infection with parvovirus B19 is almost always associated with an increased risk of transplacental fetal infection throughout the pregnancy. Fetal infection results in fetal parvovirus syndrome, which is characterized by anemia­ hydrops with cardiac failure and possibly death.
The earlier the exposure occurs, it is more likely to result in fetal parvovirus syndrome and stillbirth is the common outcome in case of third trimester infection.

Women who have been exposed to parvovirus in early pregnancy should be informed on the possible risk of fetal infection and also should be screened for parvovirus B19 specific lgG.
– If parvovirus specific lgG is positive reassure that pregnancy is not at risk
– If parvovirus specific lgG is negative, serology for lgM should be performed
After infection with parvovirus, patient’s lgM is expected to become positive within 1 to 3 weeks and it will remain high for about 8-12 weeks. lgG levels will start to rise within 2 to 4 weeks after the infection.

This woman has a negative lgG titer which indicates that she is not immune to the infection. Although her lgM titer is negative now, this does not exclude the chance of infection as it takes approximately 1 to 3 weeks after infection for lgM to become positive, and will then remain high for 8 to 12 weeks. In such cases, it is recommended the serologic tests be repeated in 2 weeks when the lgM may become positive while lgG starts to rise.

– Positive lgM titers confirm maternal parvovirus infection. If that is the case, the next step would be fetal monitoring with ultrasound for development of hydrops at 1-2 weeks intervals for the next 6-12 weeks(needs referral). Once the fetus is found to have hydrops, fetal umbilical cord sampling and intrauterine blood transfusion are considered the treatment options.
– Positive lgG and negative lgM indicates maternal immunity to parvovirus.

Interpretation of serologic tests results and the further actions recommended are as follows:

If both IgM and IgG are negative, it means mother is not immune to parvovirus B19 infection, and an infection is possible. Further action will be Repetition of serological tests in 2 weeks.

If IgM is positive and IgG is negative, it means the infection is established. Fetal monitoring with ultrasound at 1- to 2-week intervals for the next 6- 12 weeks must be done.

If both IgM and IgG are positive, it means infection is established, and an infection is possible. Further action will be fetal monitoring with ultrasound at 1- to 2-week intervals for the next 6- 12 weeks.

If IgM is negative and IgG is positive, it means the mother is immune to parvovirus infection. In this case it is important to reassure the mother that the baby is safe.

The correct answer is Obstetric Cholestasis.
The characteristics (elevated bile acids, conjugated bilirubin, and alkaline phosphatase (ALP) levels) are typical with obstetric cholestasis, which affects roughly 3-4 percent of pregnant women in Australia. Obstetric cholestasis is diagnosed when otherwise unexplained pruritus occurs in pregnancy and abnormal liver function tests (LFTs) and/or raised bile acids occur in the pregnant woman and both resolve after delivery. Pruritus that involves the palms and soles of the feet is particularly suggestive.
Liver function tests and bile acid levels measurements are used to validate this diagnosis.
All of the other diagnoses are theoretically possible, but unlikely.
On liver function tests, hepatitis A and acute fatty liver of pregnancy (which is frequently associated with severe vomiting in late pregnancy) usually show substantially worse hepatocellular damage.
Pre-eclampsia is connected with hypertension and proteinuria (along with changes in renal function and, in certain cases, thrombocytopenia), while cholelithiasis is associated with obstructive jaundice and pale stools due to a stone in the CBD.

Among all the antiepileptic drugs sodium valproate carries the highest teratogenicity rate. The potential congenital defects caused by sodium valproate are as below:
– Neural tube defects like spina bifida, anencephaly
– Cardiac complications like congenital ventricular septal defect, aortic stenosis, patent ductus arteriosus, aberrant pulmonary artery
– Limb defects like polydactyly were more than 5 fingers are present, oligodactyly were less than 5 fingers are present, absent fingers, overlapping toes, camptodactyly which is presented as a fixed flexion deformity of one or more proximal interphalangeal joints,split hand, ulnar or tibial hypoplasia.
– Genitourinary defects like hypospadias, renal hypoplasia, hydronephrosis, duplication of calyceal system.
– Brain anomalies like hydranencephaly, porencephaly, arachnoid cysts, cerebral atrophy, partial agenesis of corpus callosum, agenesis of septum pellucidum, lissencephaly of  medial sides of occipital lobes, Dandy-Walker anomaly
– Eye anomalies like bilateral congenital cataract, optic nerve hypoplasia, tear duct anomalies, microphthalmia, bilateral iris defects, corneal opacities.
– Respiratory tract defects like tracheomalacia, lung hypoplasia,severe laryngeal hypoplasia, abnormal lobulation of the right lung, right oligemic lung which is presented with less blood flow.
– Abdominal wall defects like omphalocele
– Skin abnormalities capillary hemangioma, aplasia cutis congenital of the scalp.

Anomalies of the cervico-uterus are widely diagnosed by HSG. The diagnostic value of HSG in the detection of anomalies varies, depending on the type of malformation.

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.

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.

Second-trimester ultrasound markers have low sensitivity and specificity for detecting Down syndrome, especially in a low-risk population.

The highest detection rate is acquired with ultrasound markers combined with gross anomalies. Although the detection rate with this combination of markers is high in a high-risk population (50 to 75 percent), false-positive rates are also high (22 percent for a 100 percent Down syndrome detection rate).

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.

This patient has developed clinical features like hypertension and proteinuria consistent with Pre-eclampsia. So the patient should be sent to an obstetrician for urgent review, it is not appropriate in such cases to postpone urgent specialist reviews as it could lead to serious complications.

Labetalol though is safe in pregnancy and is considered as an option to treat hypertension, it could be given in the emergency department.

In patients who have an HbA1C value above 10%, it is better to postpone pregnancy until diabetes is under control. Also in those patients with type 2 diabetes mellitus, who are suffering from severe gastroparesis, those with advanced retinopathy, with severe diabetic renal disease and severe ischemic heart disease with uncontrolled hypertension pregnancy is contraindicated.

All the other options mentioned are incorrect.

Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending foetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability.

Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities.

The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse.

In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. The definitive management of umbilical cord prolapse is expedient delivery; this is usually by caesarean section.

Alcohol exposure during pregnancy results in impaired growth, stillbirth, and fetal alcohol spectrum disorder. Fetal alcohol deficits are lifelong issues with no current treatment or established diagnostic or therapeutic tools to prevent and/or ameliorate some of these adverse outcomes.

Alcohol readily crosses the placenta with fetal blood alcohol levels approaching maternal levels within 2 hours of maternal intake. As there is known safe level of alcohol consumption during pregnancy, and alcohol is a known teratogen that can impact fetal growth and development during all stages of pregnancy, the current recommendation from the American College of Obstetricians and Gynaecologists, Centre for Disease Control (CDC), Surgeon General, and medical societies from other countries including the Society of Obstetricians and Gynaecologists of Canada all recommend complete abstinence during pregnancy.

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

The best time of the episiotomy is when the presenting part becomes visible during the contractions. If the episiotomy is performed at the proper time, less time will be required for the delivery. However, if its done too late, it causes excessive stretching of the pelvic floor and further potential lacerations.

In the given case, the patient should be treated with Augmentin.
Asymptomatic bacteriuria occurs in about 2 % to 10 % of all pregnancies and if left untreated, about 30% of this will develop acute cystitis and the other 50% will develop acute pyelonephritis.

Escherichia coli is the most common pathogen associated with asymptomatic bacteriuria, which consists more than 80% of the isolate and Staphylococcus Saprophyticus accounts for about 5-10% of isolates associated with uncomplicated UTI. Escherichia coli is a very common normal flora found in the gastrointestinal tract and Staphylococcus Saprophyticus is a commonly found normal flora in genital tract and perineum.

Asymptomatic bacteriuria has found to be associated with low birth weight and preterm birth, and it is found that a short term antibiotic treatment will help in improving the fetal outcomes in cases of asymptomatic bacteriuria or uncomplicated UTI. Hence, all cases of asymptomatic bacteriuria and uncomplicated UTI during pregnancy are recommended to be treated with a five day course of oral antibiotics as this is normally sufficient in pregnant women.

Drug of choice in asymptomatic bacteriuria (directed therapy based on sensitivities) in case of E. coli are either:
– Cephalexin 500 mg oral twice a day for 5 days or
– Nitrofurantoin 100 mg orally twice daily for 5 days or
– Trimethoprim 300 mg oral doses daily for 5 days (avoided during first trimester and in those pregnant women with established folate deficiency, low dietary folate intake, or for women taking other folate antagonists).
– Amoxicillin + clavulanate 500 + 125 mg oral, twice daily for 5 days if < 20 weeks of gestation.
Note: In view of childhood outcomes – (ORACLE II trial and 7 year follow-up), which showed an associated increase in necrotising enterocolitis, functional impairment (low), and cerebral palsy, it is recommended that amoxicillin / clavulanate is only used if no alternative treatment is available(if >20 weeks of gestation).

Asymptomatic bacteriuria (directed therapy based on sensitivities ) in case of Staphylococcus saprophyticus infection is as follows:
Cephalexin 500 mg oral doses twice a day for 5 days or Amoxicillin 500mg TDS for 5 days.

Asymptomatic bacteriuria (directed therapy based on sensitivities) in case of infection with Pseudomonas suggest Norfloxacin 400 mg oral twice daily for 5 days, then repeat MSSU 48 hours after the treatment is completed.

In case of Group B streptococcus as a single organism, Penicillin V 500 mg oral twice daily for 5 days. If the patient is hypersensitive to penicillin give Cephalexin 500 mg orally twice a day for 5 days were immediate hypersensitivity is excluded. If immediate hypersensitivity to penicillin is noticed, then Clindamycin 450 mg three times daily for 5 days is advised.

Amoxicillin is found more effective in treating UTIs caused by organisms which are resistant to the drug in vitro because of its high concentrations attainable in urine. However, a study shows that amoxicillin-resistant organisms do not respond to amoxicillin alone but Augmentin [amoxicillin clavulanate] is found to cure urinary tract infection irrespective of the amoxicillin susceptibility of the organism in vitro. Of the patients infected with amoxicillin-resistant organisms, 80% were cured by augmentin and only 10% with infection by amoxicillin-resistant organisms were cured by amoxicillin.

Now a days Amoxicillin is not preferred as the common treatment option for UTI due to increasing incidences of Escherichia coli resistance, which accounts majority of uncomplicated urinary tract infections. Clavulanic acid which is a beta-lactamase inhibitor works synergistically with amoxicillin to extend spectrum antibiotic susceptibility. This makes UTIs less likely to be resistant to the treatment with amoxicillin clavulanate compared to amoxicillin alone.
Ciprofloxacin and Gentamicin which are the other antibiotic choice considered otherwise also should be avoided in pregnancy as they comes under FDA pregnancy Category C.

Pre-eclampsia presents with other features in addition to the presence of hypertension, also it’s diagnosis cannot be made considered peripheral edema as the only presenting symptom. Proteinuria occurs more commonly in pre-eclampsia than in gestational hypertension and the latter is mostly asymptomatic.

Hypertensive disorders are found to complicate about 10% of all pregnancies. Common one among them is Gestational hypertension, which is defined as the new onset of hypertension after 20 weeks of gestation without any maternal or fetal features of pre-eclampsia, in this case BP will return to normal within three months of postpartum.

Types of hypertensive disorders during pregnancy:
1. Pregnancy-induced hypertension:
a. Systolic blood pressure (SBP) above 140 mm of Hg and diastolic hypertension above 90 mmHg occurring for the first time after the 20th week of pregnancy, which regresses postpartum.
b. The rise in systolic blood pressure above 25 mm of Hg or diastolic blood pressure above 15 mm of Hg from readings before pregnancy or in the first trimester.
2. Mild pre-eclampsia:
BP up to 170/110 mm of Hg in the absence of associated features.
3. Severe pre-eclampsia:
BP above 170/110 mm of Hg and along with features such as kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise.
4. Essential (coincidental) hypertension:
Chronic underlying hypertension occurring before the onset of pregnancy or persisting after postpartum.
5. Pregnancy-aggravated hypertension:
Underlying hypertension which is worsened by pregnancy.

To diagnose pre-eclampsia clinically, presence of one or more of the following symptoms are required along with a history of onset of hypertension after 20 weeks of gestation.
– Proteinuria: Above 300 mg/24 h or urine protein
reatinine ratio more than 30 mg/mmol.
– Renal insufficiency: serum/plasma creatinine above 0.09 mmol/L or oliguria.
– Liver disease: raised serum transaminases and severe epigastric or right upper quadrant pain.
– Neurological problems: convulsions (eclampsia); hyperreflexia with clonus; severe headaches with hyperreflexia; persistent visual disturbances (scotomata).
– Haematological disturbances like thrombocytopenia; disseminated intravascular coagulation; hemolysis.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

Women who are at high risk of having babies with neural tube defects and who would benefit from higher doses of folic acid include those with certain folate-enzyme genotypes, previous pregnancies with neural tube defects, diabetes, malabsorption disorders, or obesity, or those who take antifolate medications or smoke. Such women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

Rheumatoid arthritis and its prognosis during pregnancy are highly unpredictable, as the disease can improve in 75% of the cases and gets worse in 25%. During conception and pregnancy, it is advisable to avoid those rheumatoid arthritis medications which possess high risk in causing congenital disabilities. Most common such contraindicated remedies include methotrexate and leflunomide.
Drugs like Prednisone, Non-steroidal anti-inflammatory drugs and TNF inhibitors are also not considered safe during pregnancy, so if required these should be used under specialist supervision.

Sulfasalazine and Antimalarials such as hydroxychloroquine are safe and can be used without much complications during pregnancy. In this given case, the patient should be advised to stop methotrexate and to continue sulfasalazine during pregnancy.

Gestational trophoblastic disease (GTD) is a group of tumours defined by abnormal trophoblastic proliferation. Trophoblast cells produce human chorionic gonadotropin (hCG).

GTD is divided into hydatidiform moles (contain villi) and other trophoblastic neoplasms (lack villi). The non-molar or malignant forms of GTD are called gestational trophoblastic neoplasia (GTN).
Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. Risk factors include extremes of age, ethnicity, and a prior history of an HM which suggests a genetic basis for its aetiology.

GTD is best managed by an interprofessional team that includes nurses and pharmacists. Patients with molar pregnancies must be monitored for associated complications including hyperthyroidism, pre-eclampsia, and ovarian theca lutein cysts. Molar pregnancy induced hyperthyroidism should resolve with the evacuation of the uterus, but patients may require beta-adrenergic blocking agents before anaesthesia to reverse effects of thyroid storm. Pre-eclampsia also resolves quickly after the evacuation of the uterus. Theca lutein cysts will regress spontaneously with falling beta-HCG levels. However, patients must be counselled on signs and symptoms of ovarian torsion and ruptured ovarian cysts.

A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again.

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.

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.

This woman has developed non-specific symptoms of cervical insufficiency, is a painless dilation of cervix resulting in the delivery of a live fetus during the 2nd trimester or premature delivery.

The following has been identified as the risk factors associated with increased incidence of cervical insufficiency:
– Congenital disorders of collagen synthesis like Ehlers-Danlos syndrome.
– Prior cone biopsies.
– Prior deep cervical lacerations, which is secondary to vaginal or cesarean delivery.
-Müllerian duct defects like bicornuate or septate uterus.
– More than three prior fetal losses during the 2nd trimester

From the given options, alcohol abuse is the only one not associated with increased incidence of cervical insufficiency.

The occurrence of migraine in women is influenced by hormonal changes throughout the lifecycle. A beneficial effect of pregnancy on migraine, mainly during the last 2 trimesters, has been observed in 55 to 90% of women who are pregnant, irrespective of the type of migraine.

For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) preferably as a suppository is considered the first choice drug treatment. The risks associated with use of aspirin (acetylsalicylic acid) and ibuprofen are considered to be small when the agents are taken episodically and if they are avoided during the last trimester of pregnancy.

Paracetamol 500 mg alone or in combination with metoclopramide 10 mg are recommended as first choice symptomatic treatment of a moderate-to-severe primary headache during pregnancy.

This question is about the differential diagnoses that should be considered if a patient presents with postpartum fever. The work-up for such patients would usually involve vaginal swabs, midstream urine culture and sensitivity and an ultrasound scan of the wound to look for any presence of a haematoma. LSCS is a major surgery and one common cause of puerperal fever would be surgical site infection. It is not surprising that women who deliver via LSCS are at higher risk of developing post-partum fever compared to those who deliver vaginally. Other common causes include endometritis and UTI. Ultrasound examination of the pelvic deep venous system and the legs would also be done to look for any thrombosis. Deep vein thrombosis can occur due to immobility, however it is unlikely to present with fever.

This question assesses critical clinical knowledge, as this information must be presented to a patient prior to an amniocentesis to ensure that she has given her informed permission for the treatment.
Amniocentesis is most typically used for genetic counselling in the second trimester of pregnancy. Another option is to do a chorion-villus biopsy (CVB) between 10 and 11 weeks of pregnancy.
The chances of miscarriage after both operations are roughly 1 in 200 for amniocentesis and 1 in 100 for CVB, according to most experts.
The significance of this question is that professionals must be able to weigh the procedure’s danger against the risk of the sickness they are trying to identify.

Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

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.

A serious complication with a miscarriage is DIC, a severe blood clotting condition and is more likely if there is a long time until the foetus and other tissues are passed, which is often the case in missed abortion.

There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.

The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.

Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.

If the patient already has immunity (IgG positive) and if maternal rubella infection is the cause of the current symptoms (initial lgG and IgM negative, but IgM positive on a second sample 2-3 weeks later), amniocentesis may be required to confirm fetal infection.
Ultrasound may reveal growth limitation in late pregnancy, but a fetal congenital defect is rare when the infection begins at 10 weeks of pregnancy, and ultrasound testing at 12 weeks of pregnancy is unlikely to detect abnormalities, while it may discover one from 18-20 weeks. Given the well-known deleterious fetal effects of rubella infection in early pregnancy, gamma-globulin is unlikely to be beneficial at this point in the infective process, and pregnancy termination would certainly be considered by some individuals.
On the basis of prenatal rubella infection, this would not be recommended unless the infection was shown to have occurred.

Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.

The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic
henodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.

Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta- Mild elevation of gamma glutamyl transferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.

Indication for a transvaginal ultrasound during pregnancy include:
– to monitor the heartbeat of the foetus
– look at the cervix for any changes that could lead to complications such as miscarriage or premature delivery
– examine the placenta for abnormalities
– identify the source of any abnormal bleeding
– diagnose a possible miscarriage
– confirm an early pregnancy

This is an ultrasound examination that is usually carried out vaginally at 6-10 weeks of pregnancy.

The aims of this scan are to determine the number of embryos present and whether the pregnancy is progressing normally inside the uterus.

This scan is useful for women who are experiencing pain or bleeding in the pregnancy and those who have had previous miscarriages or ectopic pregnancies.

Research suggests the risk of having preeclampsia again is approximately 20%, however experts cite a range from 5% to 80% depending on when you had it in a prior pregnancy, how severe it was, and additional risk factors you may have. If you had preeclampsia during your first pregnancy, you may get it again. HELLP is related to preeclampsia and about 4 to 12 percent of women diagnosed with preeclampsia develop HELLP. HELLP syndrome can also cause complications in pregnancy, and if you had HELLP in a previous pregnancy, regardless of the time of onset, you have a greater risk for developing it in future pregnancies.

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

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

Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.

Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.

Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.

3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.

Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.

Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.

Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis – Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis. This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage- Because the patient’s HBsAg is negative, she is not the source of her husband’s infection. Full treatment for this patient has an efficacy of only 75%, so follow-up testing is still needed.

Normal position of the foetus in relationship to the mother is always a longitudinal lie and a cephalic presentation. Transverse lie means that the baby is sideways. The foetus lies transverse till 26-28th week of gestation, after which it usually changes its position from transverse to a longitudinal lie with head down. A transverse lie can occur in conditions like grand multiparity, preterm foetus, placenta previa and pelvic contraction.

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

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

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

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

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

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

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

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

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

Organisms frequently associated with obstetric sepsis include: beta haemolytic streptococci, Gram-negative rods such as Escherichia coli, Streptococcus pneumoniae and influenza A and B.

E. coli is the most common sepsis pathogen in pregnancy.

Meconium is the earliest stool of a newborn. Occasionally, newborns pass meconium during labour or delivery, resulting in a meconium-stained amniotic fluid (MSAF).

No particular cardio-tocograph pattern can be considered to have a poor prognostic value in the presence of thick MSAF and the decision to deliver and the mode of delivery should be based on the overall assessment and the stage and progress of labour. While management should be individualized, a higher Caesarean section rate in thick MSAF can be justified to ensure a better outcome for the neonate even in the presence of a normal CTG trace.

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

Postpartum haemorrhage (PPH) is a cumulative blood loss greater than 1000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery.

The first step in managing hemorrhagic shock is recognition. This should occur before the development of hypotension. Close attention should be paid to physiological responses to low blood volume. Tachycardia, tachypnoea, and narrowing pulse pressure may be the initial signs.

Tachycardia is typically the first abnormal vital sign of hemorrhagic shock. As the body attempts to preserve oxygen delivery to the brain and heart, blood is shunted away from extremities and nonvital organs. This causes cold and modelled extremities with delayed capillary refill. This shunting ultimately leads to worsening acidosis.

Gas gangrene is synonymous with myonecrosis and is a highly lethal infection of deep soft tissue, caused by Clostridium species, with Clostridium perfringens being the most common. This organism has also had increased incidence as the cause of deep tissue infections associated with childbirth and infections after gynaecologic procedures including septic abortions, which can cause gas gangrene of the uterus.
Health care workers should suspect gas gangrene if anaerobic gram-positive bacilli are present in a wound with necrosis of soft tissue and muscle. The organisms produce a gas identifiable on x-ray or CT scans.
Patients with gas gangrene (myonecrosis) present with signs of infection such as fever, chills, pain, and less superficial inflammation at the site of infection than one would expect given the deep penetrating nature of these infections. The condition of the patient can rapidly progress to sepsis and death if not treated aggressively. The wound discharge is often dishwater looking with a musty order.

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

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

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

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

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

Patient’s presentation is classic for uterine rupture, were she developed sudden abdominal pain followed by cessation of contractions, termination of urge to push and vaginal bleeding.
Abdominal examination shows no fetal cardiac activity and signs of fluid collection like fluid thrill and shifting dullness. The fluid collected will be blood, which usually enters the peritoneum after the rupture of the uterus. In such patients vaginal examination will reveal a range of cervical dilatation with evidences of cephalopelvic disproportion.
Anterior lower transverse segment is the most common site for spontaneous uterine rupture. Patient in the case presenting with tachycardia and hypotension is in shock due to blood loss and will require urgent resuscitation.

Placenta previa presents with painless bleeding from the vagina and Placental abruption will present with painful vaginal bleeding with tender and tense uterine wall, however, in contrary to that of uterine rupture, uterine contractions will continue in both these cases.

Shoulder dystocia is more likely to present in a prolonged labour with a significant delay in the progress of labour. However, in this case, there is no mention of shoulder dystocia.

Disseminated intravascular coagulation (DIC) is a condition which is causes due to abnormal and excessive generation of thrombin and fibrin in the circulating blood which results in bleeding from every skin puncture sites. It results in increased platelet aggregation and consumption of coagulation factors which results in bleeding at some sites and thromboembolism at other sites. Placental abruption, or retained products of conception in the uterine cavity are the causes for DIC.

In this case, the patient has a missed abortion, which is defined as a dead foetus or embryo without passage of tissue and with a closed cervix. This condition often presents with failure to detect fetal heart tones or a lack of growth in uterine size.

– By 14 weeks estimated gestational age, fetal heart tones should be detected by both handheld Doppler and ultrasonography.
– An inevitable abortion presents with a dilated cervix, but no passage of fetal tissue.
– A blighted ovum involves failure of the embryo to develop, despite the presence of a gestational sac and placental tissue.

Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.

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.

Twin gestations are generally at increased risk of complications and this risk is further stratified based on the chorionicity ie. number of placentas and amnionicity, the number of amniotic sacs of the gestation. In the given case patient has monochorionic diamniotic twins, which means 1 placenta and 2 amniotic sacs, based on the presence of 2 embryos, a single placenta and a thin intertwin membrane composed of 2 amniotic sacs that meets the placenta at a 90-degree angle (“T sign”). In patients who appear to have a single placenta, the base shape of the intertwin membrane distinguishes between a monochorionic (“T sign”) and fused dichorionic (“lambda sign”) gestation.
Monochorionic twins are at high risk for twin-twin transfusion syndrome (TTTS), which is a complication that can result in heart failure and fetal
eonatal mortality in both twins. In TTTS, unbalanced arteriovenous anastomoses are present between the shared placental vessels that supply the twins, because of these anastomoses, blood from the placental arteries from one twin (donor), which is of high resistance/pressure, is shunted into the placental veins of the other twin (recipient) with low resistance/pressure. This shunting of blood away from the donor twin causes anemia that leads to renal failure, oligohydramnios, low-output heart failure, and fetal growth restriction. In contrast, the shunting of blood toward the recipient twin causes polycythemia, which leads to polyhydramnios, cardiomegaly, high-output heart failure and hydrops fetalis. This in turn makes both twins at high risk for intrauterine and neonatal death.
Mild TTTS is expectantly managed with serial ultrasounds to evaluate for worsening clinical features, whereas moderate-to-severe cases are treated with laser coagulation of the placental anastomoses.

In monozygotic twins, placentation type is determined by timing of the twinning.  Twinning that occurs shortly after fertilization yields a dichorionic diamniotic gestation.  In contrast, the incomplete division (ie, fission) that can lead to conjoined twins occurs later in development and yields a monochorionic monoamniotic gestation. As the twins are in the same sac, monochorionic monoamniotic gestations can be complicated by cord entanglement but not possible in the given case as this patient has diamniotic twins.

Risk factors for placenta accreta, implantation of the placenta directly into the myometrium, include placenta previa and prior uterine surgeries like cesarean delivery, myomectomy, etc

Twin pregnancies are at increased risk of placenta previa (placental tissue that covers the internal cervical os); however, this patient has a fundal placenta, making this complication unlikely.

Monochorionic twin gestations can be complicated by twin-twin transfusion syndrome, which is potentially a fatal condition that results from unbalanced vascular anastomoses between the vessels supplying umbilical cords of each twin.

Dizygotic twin pregnancies are known to increase with age of the mother. Naturally conceived twins are thought to occur in a 0.3% rate in women under 25 years, 1.4% between 25 and 34, 3% between 34 and 39, and 4.1% in women in their 40s or over. We also know that at least 50% of all twin pregnancies are conceived through ART and that this proportion is probably higher for women in their 40s.

The effects of smoking on the outcomes of pregnancy are well documented and include an increased risk of preterm premature rupture of the membranes (PPROM), preterm birth, low birth weight, placenta previa, and placental abruption. Many studies have shown that the risk of Sudden Infant Death Syndrome (SIDS) is increased by maternal smoking during pregnancy.

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimetres from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimetres.

A fundal height that measures smaller or larger than expected — or increases more or less quickly than expected — could indicate:
– Slow fetal growth (intrauterine growth restriction)
– A multiple pregnancy
– A significantly larger than average baby (fetal macrosomia)
– Too little amniotic fluid (oligohydramnios)
– Too much amniotic fluid (polyhydramnios).

This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.

In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.

Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.

Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.

Common risk factors for Rectovaginal fistula are Pelvic radiation, Obstetric trauma, Pelvic surgery, Colon cancer, Diverticulitis and Crohn disease. Uncontrollable passage of gas &/or feces from the vagina is considered the common clinical feature of Rectovaginal fistula.
Diagnosis is done with the help of physical examination, fistulography, Magnetic resonance imaging and Endosonography.

This patient, mentioned in the case, presents with malodorous vaginal discharge (ie, stool), gas passing through the vagina, and a posterior vaginal lesion most likely has a rectovaginal fistula, which is an aberrant connection between bowel and vagina.  Although development of rectovaginal fistula is commonly associated with obstetric trauma or pelvic surgery, patients without these risk factors are recommended to be evaluated for other additional causes like gastrointestinal conditions.
This patient’s intermittent, crampy abdominal pain and perianal sinus in the setting of a rectovaginal fistula is most likely due to an underlying Crohn disease.  Crohn disease, is a transmural inflammation of the gastrointestinal tract, which predisposes patients to bowel abscess, fissure, and fistula formation.  Although the rectum is typically spared in Crohn disease, a non-healing, transmural ulcer present in the anal canal can progress to form a rectovaginal fistula.
In addition to standard Crohn disease management like anti-TNF inhibitors, glucocorticoids, etc patients with a rectovaginal fistula may require surgical correction.

Bartholin gland cysts or abscesses can present with malodorous vaginal discharge; however, patients typically have a posterior vulvar mass located at the 4 or 8 o’clock position. In addition, Bartholin gland cysts will not present with crampy abdominal pain or passage of flatus or stool through the vagina.

Hidradenitis which is the chronic occlusion and inflammation of hair follicles, can cause groin abscesses with sinus tracts and associated purulent drainage.  However, it is not associated with abdominal pain or malodorous vaginal discharge. In addition, this condition is typically multifocal and located in more than one intertriginous areas like axillary, inguinal or gluteal regions.

Cervical cancer or a retained foreign body in the vagina can cause malodorous vaginal discharge and abdominal pain.  However, patients will typically have visible findings like cervical lesion, foreign body etc on speculum examination, and these neither are associated with the passage of flatus through the vagina.

Complications of Crohn disease include perianal disease like abscess, fissure and fistula like rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract.  Patients with a rectovaginal fistula typically presents with malodorous, tan vaginal discharge, passage of flatus through the vagina and a posterior vaginal lesion.

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.

Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, leading to shortness of breath, dizziness, fainting, and other symptoms, all of which are exacerbated by exertion. PH in pregnancy carries a 25–56% maternal mortality rate with a mixture of intrapartum and postpartum deaths.

Current recommendations for management of PH in pregnancy include termination of pregnancy if diagnosed early, or utilizing a controlled interventional approach with early nebulized prostanoid therapy and early elective caesarean section under regional anaesthesia. Other recommended therapies for peripartum management of PH include sildenafil and nitric oxide.

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.

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

Amniocentesis is a prenatal procedure performed on a pregnant woman to withdraw a small amount of amniotic fluid from the sac surrounding the foetus.
The goal of amniocentesis is to examine a small amount of this fluid to obtain information about the baby, including its sex, and to detect physical abnormalities such as Down syndrome or spina bifida.
Amniocentesis is only performed on women thought to be at higher risk of delivering a child with a birth defect.

Amniocentesis is performed between 16 and 20 weeks into the pregnancy. By around this time, the developing baby is suspended in about 130ml of amniotic fluid, which the baby constantly swallows and excretes. A thin needle is used to withdraw a small amount of this fluid from the sac surrounding the foetus.

Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.

Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia.

In high-risk pregnancies, continuous monitoring of foetal heart rate is considered mandatory.

However, in low-risk pregnancies, cardiotocograph (CTG) monitoring provides no benefits over intermittent auscultation.

A significant issue with CTG monitoring is that apparent abnormalities are identified that usually have minimal clinical significance, but can prompt the use of several obstetric interventions such as instrumental deliveries and Caesarean section. In low risk patients, such interventions may not even be required.

CTG monitoring has not been shown to reduce the incidence of cerebral palsy or other neonatal developmental abnormalities, nor does it accurately predict previous foetal oxygenation status unless the CTG is significantly abnormal when it is first connected.

Similarly, CTG cannot accurately predict current foetal oxygenation unless the readings are severely abnormal.

Therefore, there is no evidence to support routine admission CTG (correct answer).

The postpartum period begins soon after the baby’s delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state.

Bloody vaginal discharge (lochia rubra) is heavy for the first 3-4 days, and slowly it becomes watery in consistency and colour changes to pinkish-brown (lochia serosa). After the next 10-12 days, it changes to yellowish-white (lochia alba). Advise women to seek medical attention if heavy vaginal bleeding persists (soaking a pad or more in less than an hour). Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, rarely invasive placenta, or coagulation disorders. Endometritis may also occur, presenting as fever with no source, maybe accompanied by uterine tenderness and vaginal discharge. This usually requires intravenous antibiotics. This also should be explained and advise the mother to seek immediate medical attention.

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.

Pregnant women need to get enough folic acid. The vitamin is important to the growth of the foetus’s spinal cord and brain. Folic acid deficiency can cause severe birth defects known as neural tube defects. The Recommended Dietary Allowance (RDA) for folate during pregnancy is 600 micrograms (µg)/day.

Trauma is a major contributor for maternal mortality and is one of the leading causes of pregnancy-associated maternal deaths.

As a result of maternal hypotension or hypoxemia, placental abruption, uterine rupture or fetal trauma a maternal trauma can compromise the fetus also.
Patient’s bruises on the abdomen which are seatbelt marks, are indications that this woman has positioned the seat belt incorrectly over the uterus. So there is a good chance that the uterus and its contents, including the fetus, has been affected by the impact. In a pregnant woman, the correct position of seat belt is when the lap belt is placed on the hip below uterus and the sash is placed between breasts and above the uterus.

A minimum of 24-hour period monitoring is recommended for all pregnant women, apart from the routine trauma workup indicated in non-pregnant women, in case they have sustained trauma in the presence of any of the following:
– Regular uterine contractions
– Vaginal bleeding
– A non-reassuring fetal heart rate tracing
– Abdominal/uterine pain
– Significant trauma to the abdomen

Considering the bruises over her abdomen this patient should be considered as having significant abdominal trauma and must be kept under observation for a minimum of 24 hours. Such patients should not be discharged unless the clinician makes sure they do not have any complications like abruption or preterm labor.

If a mother has been abusing drugs during antenatal period, there are some contraindications to discharge her baby home. These conditions includes:
– excessive weight loss, which is greater than ten percent of birth weigh
– suspected baby neglect or abuse
– suspected domestic violence
– a court order preventing baby from being discharged home or if there is requirement for further assessment of withdrawal symptoms.

A 2-3 percentages weight loss during the early neonatal period is considered to be a normal finding and is therefore not considered as a contraindication to discharge the baby home.

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.

About 1 in 4 pregnant women carry GBS bacteria in their body. Doctors should test pregnant woman for GBS bacteria when they are 36 through 37 weeks pregnant.

Giving pregnant women antibiotics through the vein (IV) during labour can prevent most early-onset GBS disease in newborns. A pregnant woman who tests positive for GBS bacteria and gets antibiotics during labour has only a 1 in 4,000 chance of delivering a baby who will develop GBS disease. If she does not receive antibiotics during labour, her chance of delivering a baby who will develop GBS disease is 1 in 200.

Pregnant women cannot take antibiotics to prevent early-onset GBS disease in newborns before labour. The bacteria can grow back quickly. The antibiotics only help during labour.

Antepartum haemorrhage presents with bleeding, which may or may not be accompanied by pain. Uterine irritability would suggest abruptio, however contractions are present which may be confused with uterine irritability and in this case, there are no signs of pre-eclampsia present.

Anticoagulant therapy is the standard treatment for deep vein thrombosis (DVT) but is mostly used in non-pregnant patients. In pregnancy, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are commonly used. Warfarin therapy is generally avoided in pregnancy because of its fetal toxicity.

Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy.

At the 36‑week appointment, all pregnant women should be seen again. At this appointment: measure blood pressure and test urine for proteinuria; measure and plot symphysis–fundal height; check position of baby; for women whose babies are in the breech presentation, offer external cephalic version (ECV)

Clotting factor problem. Some of the more common disorders of coagulation that occur during pregnancy are von Willebrand disease, common factor deficiencies, platelet disorders and as a result of anticoagulants.

Shoulder dystocia occurs when the bisacromial diameter, which is the breadth of the shoulders, exceed the diameter of pelvic inlet. This typically results in a bony impaction of the anterior shoulder against the maternal symphysis pubis, instead of an arrest at the pelvic inlet. Brachial plexus palsies including Erb’s palsy is the most common foetal injury associated with shoulder dystocia.

It is not hyper-extension but the hyper-flexion of maternal legs tightly on her abdomen, called as McRoberts manoeuvre, which facilitates delivery during shoulder dystocia. This technique is effective as it increases the mobility of sacroiliac joint during pregnancy, which allows the rotation of pelvis and thereby facilitating the release of fetal shoulder.
If this manoeuvre does not succeed, another technique called suprapubic pressure is done where an assistant applies pressure on the lower abdomen and gently pulls the delivered head. This technique is useful in about 42% of cases with shoulder dystocia.

Maternal diabetes mellitus and foetal macrosomia both are a risk factor for shoulder dystocia.

Administration of epidural anaesthesia during labour increases the possibility of shoulder dystocia.

Risk of shoulder dystocia may increase with Oxytocin augmentation also.

Obstetric complications during or following a cesarean section delivery include:
-Increased risk of maternal mortality.
-Increased need for cesarean sections in the subsequent pregnancies.
-Increased risk for damage to adjacent visceral organs especially bowels and bladder.
-Increased risk of infections.

Increased risk for formation of adhesions is a complication after cesarean section and this is the correct response for the given question.

Free T3 (FT3) and free T4 (FT4) levels are slightly lower in the second and third trimesters. Thyroid-stimulating hormone (TSH) levels are low-normal in the first trimester, with normalization by the second trimester.

A screening blood test for the infectious diseases HIV, Syphilis, Rubella, Toxoplasmosis and Hepatitis B is offered to all pregnant females so as to reduce the chances of transmission to the neonate.

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

The finding of ketonuria in this patient indicates profound dehydration and electrolyte loss. Immediate investigation with baseline serum electrolytes, urea, and creatinine is recommended for aid In intravenous resuscitation and rehydration.

All other assessments listed are appropriate, however, baseline electrolyte concentration is important before initiating intravenous resuscitation.

Other causes that can lead to vomiting in early pregnancy include normal pregnancy, multiple pregnancies, molar pregnancies, or urinary tract infection. Urine culture is necessary to exclude urinary tract infection, pelvic ultrasound to confirm singleton or multiple pregnancy and rule out a molar pregnancy.

An erect abdominal Xray may help to rule out an organic intestinal obstruction in this patient. Her history of an appendectomy predisposes this patient to adhesions leading to small bowel obstruction. However, it is not the immediate assessment in this case.

Before the advent of ultrasound, a quantitative hCG analysis was indicated to assess the presence of molar pregnancy. However, ultrasound is now preferred to confirm this diagnosis.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

To help protect babies during this time when they are most vulnerable, women should get the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.

Pregnant women should receive Tdap anytime during pregnancy if it is indicated for wound care or during a community pertussis outbreak.
If Tdap is administered earlier in pregnancy, it should not be repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.

Optimal timing is between 27 and 36 weeks gestation (preferably during the earlier part of this period) to maximize the maternal antibody response and passive antibody transfer to the infant.
Fewer babies will be hospitalized for and die from pertussis when Tdap is given during pregnancy rather than during the postpartum period.

Atenolol and propranolol are associated with intrauterine growth retardation when used for prolonged periods during pregnancy. They are class D agents during pregnancy. Other beta-blockers may not share this risk.

Methyldopa, hydralazine, and calcium channel blockers have not been associated with intrauterine growth retardation. They are generally acceptable agents to use for established, significant hypertension during pregnancy.

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.

Station 0 – This is when the baby’s head is even with the ischial spines. The baby is said to be engaged when the largest part of the head has entered the pelvis.
If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

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.

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

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

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

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

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

Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

A 20 weeks pregnant patient has developed goitre along with thyrotoxicosis, where the diagnosis of thyrotoxicosis has already been established.
Ultrasound of the thyroid and a radioisotope scan to differentiate between “hot” and “cold” nodules are the confirming investigations for goitre. A nodule composed of cells that do not make thyroid hormone and the nodule which produces too much thyroid hormone are respectively called as cold and “hot” nodules.

Due to the risk of fetal uptake of the isotope which leads to the damage of fetal thyroid, radioisotope or radionuclide Technetium uptake scan is contraindicated in pregnancy.

Fine needle aspiration cytology is required to establish a histopathological diagnosis in case of all cold nodules.

So ultrasound of the thyroid gland is the mandatory investigation to be done in this case as it will show diffuse enlargement, characteristic of the autoimmune disease, or multinodularity, which is suggestive of autonomous multinodular goitre.

Administration of warfarin should be avoided throughout pregnancy and especially during the first and third trimesters as it have the ability to cross placenta. Intake of warfarin during 6-12 weeks of gestation can results in fetal warfarin syndrome which is characterized by the following features:
– A characteristic nasal hypoplasia
– Short fingers with hypoplastic nails
– Calcified epiphyses, namely chondrodysplasia punctata, which is evident on X-ray as stippling of the epiphyses.
– Intellectual disability
– Low birth weight

As these effects are usually dose dependent, recent estimates shows that the risk of fetal warfarin syndrome is around 5% in babies of women who requires warfarin throughout pregnancy.
Later exposure as after 12 weeks, is associated with symptoms like central nervous system anomalies, including microcephaly, hydrocephalus, agenesis of corpus callosum, Dandy-Walker malformation which is presented with complete absence cerebellar vermis and enlarged fourth ventricle, and mental retardation, as well as eye anomalies such as optic atrophy, microphthalmia and Peter anomaly (anterior segment dysgenesis).
Those newborns exposed to warfarin in all three trimesters there will be blindness and other complication of exposed to warfarin in neonates include perinatal intracranial and other major bleeding episodes.

According to the laboratory reports, patient has developed urinary tract infection and should be treated with one week course of oral antibiotics.
As the patient is pregnant, antibiotics like cephalexin, co-amoxiclav and nitrofurantoin must be considered as these are safe during pregnancy.

Due to this Patient’s allergic history to penicillin, cephalexin can be considered as the best option. Risk of cross allergy would have been higher if the patient had any history of anaphylactic reactions to penicillin.

In Australia, Amoxicillin is not recommended to treat UTI due to resistance.Tetracyclines also should be avoided during pregnancy due to its teratogenic property.

Repetitive late decelerations can be caused by fetal hypoxia which results in constriction of the vessels to circulate blood from the peripheries to more important organs of the body like the brain and heart etc.