Phosphate and ammonia are the major urinary buffers

It is less common for a girl of this age to develop fibroids, endometriosis and endometrial polyps, although these are all causes of severe dysmenorrhea. Chronic pelvic infection can be due to sexually transmitted disease but the history does not mention any previous episodes of pelvic pain or symptoms of infection such as fever. In this case, it is most likely that she has primary dysmenorrhea. Primary dysmenorrhea, in which no pathological cause can be identified, is believed to be due to the prostaglandins released by the secretory endometrium. If secondary dysmenorrhea is suspected, then endometriosis would be the most prominent cause.

While hysteroscopic and laparoscopic examinations are commonly done in adult women to rule out organic causes such as those mentioned earlier, in younger girls, they are usually only carried out if pain management with, for example, NSAIDs and the use of COCPs, have failed to either provide symptom relief or reduction.

The ovarian artery takes its origin directly from the aorta. While the uterine and the vaginal arteries are all branches of the internal iliac artery.

Acute fatty liver of pregnancy occurs in 1-10000 pregnancies and presents as jaundice with abdominal pain. The maternal mortality is around 20%

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

Women who have used oral contraceptives for 5 years or more are more likely to get cervical cancer than women who have never used them. The longer a woman uses oral contraceptives, the higher her chances of developing cervical cancer become. According to one study, using marijuana for less than 5 years increases the risk by 10%, using it for 5–9 years increases the risk by 60%, and using it for 10 years or more increases the risk by double. After women cease using oral contraceptives, their risk of cervical cancer appears to decrease over time. Endometrial, ovarian, and colorectal cancer risks, on the other hand, are lowered.
Compared to women who had never used oral contraceptives, women who were taking or had just discontinued using oral combination hormone contraceptives had a slight (approximately 20%) increase in the relative risk of breast cancer. Depending on the type of oral combination hormone contraception used, the risk increased anywhere from 0% to 60%. The longer oral contraceptives were used, the higher the risk of breast cancer.

The Rotterdam criteria for the diagnosis of PCOS is based on a score of two out of the three criteria:
1) Oligo or anovulation
2) Hyperandrogenism – clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
3) on ultrasound – contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 cm3 or greater.

Ergometrine has a half life of 30-120 minutes.

Significant proteinuria = urinary protein:creatinine ratio >30 mg/mmol or 24-hour urine collection result shows greater than 300 mg protein

Pregnant maternal serum AFP levels elevated: Neural tube defects (e.g., spina bifida, anencephaly); Omphalocele; Gastroschisis.

Pregnant maternal serum AFP low levels: Down syndrome

Abnormal uterine bleeding is a relatively common disorder which may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.

Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problem or for older women. Oestrogen would only increase the problem, which is usually due to anovulation with prolonged oestrogen secretion, producing a hypertrophic endometrium.

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

Circulation in the foetus: 1. Deoxygenated fetal blood is conducted to the placenta via the two umbilical arteries. The umbilical arteries arise from the internal iliac arteries.
2. Gas exchange occurs in placenta.
3. Oxygenated blood from the placenta passes through the single umbilical vein and enters the inferior vena cava (IVC).
4. About 50% of the blood in the IVC passes through the liver and the rest bypasses the liver via the ductus venosus. The IVC also drains blood returning from the lower trunk and extremities.
5. On reaching the heart, blood is effectively divided into two streams by the edge of the interatrial septum (crista dividens) (1) a larger stream is shunted to the left atrium through the foramen ovale (lying between IVC and left atrium) (2) the other stream passes into right atrium where it is joined by blood from SVC which is blood returning from the myocardium and upper parts of body. This stream therefore has a lower partial pressure of oxygen.
6. Because of the large pulmonary vascular resistance and the presence of the ductus arteriosus most of the right ventricular output passes into the aorta at a point distal to the origin of the arteries to the head and upper extremities. The diameter of the ductus arteriosus is similar to the descending aorta. The patency of the ductus arteriosus is maintained by the low oxygen tension and the vasodilating effects of prostaglandin E2;
7. Blood flowing through the foramen ovale and into left atrium passes into the left ventricle where it is ejected into the ascending aorta. This relatively oxygen rich blood passes predominantly to the head and upper extremities.

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

This lady is most likely suffering from primary syphilis. Since the chancre is asymptomatic, it is often only found on deep examination of the vulvo-vaginal mucosa. The chief organism causing syphilis is Treponema Pallidum which is a spirochete and one of the most widely distributed sexually transmitted infections.

Shoulder dystocia is a complication associated with fetal macrosomia and may result in neurological dysfunction. Fetal macrosomia is generally defined as birth weight – 4,000 g. It occurs in about 10% of pregnancies and one of the most important predictors of fetal macrosomia is previous macrosomic infant(s). The recurrence rate of fetal macrosomia is above 30%. Other risk factors are maternal diabetes, multiparity, prolonged gestation, maternal obesity, excessive weight gain, male foetus, and parental stature- Not all cases of fetal macrosomia lead to shoulder dystocia and the occurrence of this complication is only 0.5%-1% of all pregnancies.

To make clinical decision regarding management of the patient, it is important to understand that there are other factors that lead to shoulder dystocia, such as the mother’s anatomy. While statistics suggest that there’s a tendency to choose elective Caesarean delivery for suspected macrosomia, it is believed that most of procedures are unnecessary, as evidence has shown the number of complications are not reduce- Also while it is logical to consider induction of labour at the 37th week of pregnancy, it is associated with increased Caesarean deliveries because of failed inductions. The recommended course of action is watchful waiting till the patient goes in labour.

→ Induce labour at the 37th week of gestation is not the best course of action, as it is associated with high failure rate, which often leads to Caesarean delivery.
→ Schedule elective Caesarean delivery is considered unnecessary in patients who do not have diabetes. Statistics have shown no evidence that Caesarean delivery reduces the rate of complications.
→ Serial ultrasound for fetal weight estimation is incorrect. The strategies used to predict fetal macrosomia are risk factors, Leopold’s manoeuvres, and ultrasonography. Even when they are combined, they are considered inaccurate; much less ultrasonography alone.
→ At this point, blood glucose control in pregnancies associated with diabetes seems to have desired results in preventing macrosomia- A weight loss program is usually not recommended- Instead, expectant management should be considered.

Cilia are small hair line projections in the fallopian tube. Their main function is to transport the egg through he fallopian tube towards the uterus. It is present in many other tubular organs and its function varies accordingly to the organ.

The use of anticoagulants during pregnancy is a complicated issue because warfarin is teratogenic if used in the first trimester, and is linked with fetal intracranial haemorrhage in the third trimester (mainly at doses 5 mg daily). Low molecular weight heparin may be insufficient at preventing thrombosis in women with mechanical prosthetic heart valves, where the risk of valve thrombus is 10 per cent. Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension, or artificial valve replacements, and in those in or at risk of atrial fibrillation. The options are either to continue warfarin for the pregnancy, or replace it with heparin between 6 and 12 weeks gestation to avoid the teratogenic risk. Warfarin should be started a week after delivery.

The incidence of listeria infection in pregnant women is estimated at 12 per 100 000 compared to 0.7 per 100 000 in the general population.

Pregnant women with high-grade squamous intraepithelial lesions (HSIL) on cervical cytology should be evaluated with colposcopy. Principles of management of pregnant women include the following:
– An immediate diagnostic excisional procedure should NOT be performed.
– When colposcopy is performed during pregnancy:
– Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy; however, the endocervical canal may be sampled gently with a cytobrush.
– Cervical biopsy should be performed only if a lesion is present that appears to be high grade or suspicious for cancer.
– If the examination is unsatisfactory, repeating the colposcopy after 6 to 12 weeks should allow visualization of the entire squamocolumnar junction.

There is no indication for inducing abortion or performing a hysterectomy.

In pregnancy, although it is a hypercoagulable state with an increase in clotting factors, the platelet count is decreased. Fibrinogen and erythrocyte sedimentation rate (ESR) may be both increased.

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

2010 FIGO classification of cervical carcinoma

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

Shortly after the Morula enters into the uterus, approximately on the 4th day after fertilization a fluid filled cystic cavity appears in the morula and transforms the morula into a blastocyst.

Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate to allow the foetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large foetus, an unfavourable orientation of the foetus, or a combination of these factors. Diagnosis of CPD may be made when there is failure to progress, but not all cases of prolonged labour are the result of CPD. Use of ultrasound to measure the size of the foetus in the womb is controversial, as these methods are often inaccurate and may lead to unnecessary caesarean section; a trial of labour is often recommended even if size of the foetus is estimated to be large.

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.

The diagnosis of listeria depends on clinical suspicion and isolation of the organism from blood, vaginal swabs or the placenta. Meconium staining of the amniotic fluid in a preterm foetus may increase clinical suspicion for listeriosis. For women with listeriosis during pregnancy, intravenous antibiotic treatment (ampicillin 2 g given every 6 hours) is indicated.

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.

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

Around 30-40% of women affected by this condition complain of difficulty in conceiving.

Mirena is a form of contraception also indicated for the treatment of heavy menstrual bleeding and the management of dysmenorrhea, being able to reduce the latter considerably.