Closure of the uterus should be performed in either single or double layers with continuous or interrupted sutures. The initial suture should be placed just lateral to the incision angle, and the closure continued to a point just lateral to the angle on the opposite side. A running stitch is often employed and this may be locked to improve haemostasis. If a second layer is used, an inverting suture or horizontal suture should overlap the myometrium. Once repaired, the incision is assessed for haemostasis and ‘figure-of-eight’
sutures can be employed to control bleeding. Peritoneal closure is unnecessary. Abdominal closure is performed in the anatomical planes with high strength, low reactivity materials, such as polyglycolic acid or polyglactin. Diamorphine is advised for intra and post op analgesia and oxytocin is advised to reduce blood loss.

The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.

The pudendal nerve provides sensory innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. Pudendal nerve blocks are indicated for analgesia of the second stage of labour, repair of an episiotomy or perineal laceration, and for minor surgeries of the lower vagina and perineum.

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.

Tissues with actively dividing cells, such as bone marrow and gastrointestinal mucosa, are particularly sensitive to ionising radiation. Lymphocyte depletion is the most sensitive marker of bone marrow injury, and after exposure to
a fatal dose, marrow aplasia is a common cause of death. The gonads are highly radiosensitive and radiation may result in temporary or permanent sterility. Stochastic (chance) effects occur with increasing probability
as the dose of radiation increases. Carcinogenesis represents a stochastic effect. With acute exposures, leukaemias may arise after an interval of around 2–5 years and solid tumours after an interval of about 10–20 years. Moist skin desquamation can be an acute reaction to both radio and chemotherapy whereas fibrosis and lymphoedema are late complications.

The uterus needs support in order to remain centered inside the pelvic cavity. The support it receives comes in two forms: dynamic and passive. The ligaments of the uterus have an important role in both.

Dynamic support is provided by the pelvic diaphragm through tonic contractions while standing and sitting and active contractions during moments of increased abdominal pressure, such as coughing or sneezing. During these moments, the ligaments of the uterus transmit the force of the diaphragm towards the organ itself, maintaining its position.

The ligaments are also crucial in providing passive support. By minimizing movement of the body and the cervix, they maintain the uterus in the typical anteverted and anteflexed position directly on top of the bladder. This provides a support for the uterus when the abdominal pressure increases.

Hence, even though the broad ligament, round ligament and ovarian ligament have some role in the suspension of the uterus, the uterosacral ligament plays the most significant role. It is also the ligament used for surgical suspension of POP.

The basic components of the mammary gland are the alveoli. These are lined with milk-secreting cuboidal cells surrounded by myoepithelial cells. The alveoli join to form groups known as lobules. The lobules form lobes. Each lobe has a lactiferous duct that drains into openings in the nipple. Each breast typically contains 15-20 lobes.

Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.

A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).

Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.

PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.

Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.

Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.

Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).

In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.

The Vaginal artery, like the Uterine artery is typically a branch of the Internal Iliac artery. It can sometimes arise as a branch of the Uterine artery so it is important to read the question (if the stem stated it CAN arise from the Uterine artery then that would be true)

Most carcinomas spread primarily via lymphatic invasion. Renal cell is the exception spreading via the bloodstream.

Mefenamic acids is a NSAID. It works by inhibiting prostaglandin synthesis – It inhibits COX-1 and COX-2 hence reducing the process of inflammation. Activation of antithrombin III and inactivation of factor Xa is the primary mechanism of action of Heparin.

Risk factors of fibroids include early menarche, nulliparity, early exposure to oral contraceptives (one study showed 13-16 years old), diet rich in red meats and alcohol, vitamin D deficiency, hypertension, obesity, and/or history of sexual or physical abuse.

Smoking is associated with actual reduced risk due to an unknown mechanism.

E.coli is the most common cause of UTI. Other organisms include pseudomonas, proteus and klebsiella.

NICE guidelines: UTI in pregnancy (updated in July 2015)

Send urine for culture and sensitivity from all women in whom UTI is suspected before starting empirical antibiotics and 7 days after antibiotic treatment is completed.
Prescribe an antibiotic to all women with suspected UTI (awaiting culture result is not advised)
Although local antibiotic resistance needs to be taken into account the following is advised in terms of antibiotic selection:
1. Nitrofurantoin 50 mg QDS (or 100 mg MR BD) for 7 days.
2. Trimethoprim 200 mg twice daily, for 7 days
Give folic acid 5 mg OD if it is the 1st trimester
Do not give trimethoprim if the woman is folate deficient, taking a folate antagonist, or has been treated with trimethoprim in the past year.
3. Cefalexin 500 mg BD (or 250 mg 6qds) for 7 days

The ischial spines and palpable through the vagina and are used as landmarks to assess the decent of the fetal head from the cervix. It also serves as a landmark for giving the pudendal block.

Among a variety of imaging modalities developed for breast cancer screening, mammography is the best-studied and the only imaging technique that has been shown to decrease mortality as demonstrated in multiple randomized trials. However, it is important to know that, even in the best circumstances, mammography may miss up to 20 percent of underlying breast cancers.

Women on HRT are likely to have dense breast. Dense breasts are associated with an increased risk of breast cancer and can decrease the sensitivity of mammography for small lesions. Nevertheless, we do not alter our general approach to age- and risk-based screening based on breast density. However, for women with dense breasts, we do prefer digital mammography over film mammography, due to greater sensitivity; digital mammography is the modality typically used for mammography in most locations in the United States.

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

The Fallopian tubes, also known as, uterine tubes, and salpinges, are two very fine tubes lined with ciliated columnar epithelia, leading from the ovaries of female mammals into the uterus, via the uterotubal junction.

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

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

Screening for gestational diabetes should be offered and performed between 24-28 weeks. It should be noted PCOS alone does not make screening essential. It is advised for PCOS patients who are overweight or if not overweight but has other risk factors (age >40, personal history of gestational diabetes or family history of type II diabetes). Screening is via a 2-hour post 75 g oral glucose tolerance test.