In pregnancy, term refers to the gestational period from 37 to 41+6 weeks. Preterm births occur between 24 and 36+6 weeks. Only 1% of women who go into PROM have risk of having serious neonatal infections.

Management of PROM:
60% of patients with PROM will go into labour within 24 hrs
Induction is appropriate if >34 weeks gestation and more than 24 hours post rupture when labour hasn’t started.
If < 34 weeks, induction of labour should not be carried out unless there are additional obstetric indications e.g. infection

Radiotherapy causes ionisation, primarily of water. This leads to hydroxyl and other free radicals being generated. Free radicals are highly reactive and cause DNA damage to cells via their reactions with them. Free radicals are relatively short lived and eventually form stable compounds. The DNA damage leads to cellular death.

Puberty is the process of reproductive and sexual development and the maturation which changes a child into an adult.

Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement.

The Pudendal provides cutaneous innervation to the posterior external genitalia via one of its terminal branches called the perineal nerve (this further branches into the posterior labial nerves or posterior scrotal nerve in men). The ilioinguinal nerve provides anterior sensation via the anterior labial nerves (anterior scrotal nerve in men). The genital branch of the genitofemoral nerve contributes some fibres to the skin of the mons pubis and labia majora in females. The posterior cutaneous nerve of thigh sometimes overlaps sensory areas.

The superior mesenteric vein joins the splenic vein to form the hepatic portal vein.

Mitosis is the process during which cell division occurs. It is divided into 4 stages:
– The first stage is the prophase during which the chromosomes condense, mitotic spindles form and the chromosomes pair which each other.
– The second stage is the metaphase during which the chromatids align at the equatorial plane.
– The third stage is the anaphase during which the chromatids are separated into 2 daughter chromosomes.
– The fourth phase is the telophase during which the chromatids decondense and a new nuclear envelop forms around the each of the daughter chromosomes. Cytokinesis is the process during which the cell cytoplasm divides.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a nonstress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.

The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

Radiotherapy works on the principle of ionisation. In particularly that of water leading to the formation of free radicals, these radicals are highly reactive and they react with the DNA leading to damage and cell death.

Patient mentioned above is a known case of type 2 diabetes which makes her at high risk of having neural tube defects. She should be advised to start taking a high dose of (5mg) folic acid supplement daily for at least 1-month prior to conception and it should be continued upto 12 weeks of her pregnancy.

Folate, which is a water-soluble B vitamin, is usually obtained from diet or through supplementation. For those patients with a history of type 2 diabetes mellitus, who are planning for pregnancy, high doses are recommended to prevent any possible neural tube defects.

Vitamin A is not safe and should be avoided in pregnancy due to chances for toxicity.

Vitamin C and iron are not considered as essential vitamins to be taken during pregnancy.

Progestogen-only methods are contraindicated in suspected pregnancy, breast cancer and undiagnosed vaginal bleeding. Giving DMPA to a woman with a severe bleeding disorder may result in a large haematoma at the injection site.

Women who want to become pregnant within 18 months or who are afraid of injections should be discouraged from using DMPA. Progestogen-only methods are unsuitable for women unwilling to accept menstrual changes.

Relative contraindications are active viral hepatitis and severe chronic liver disease. For all progestogen-only methods, with the possible exception of DMPA, drug interactions are likely with many anticonvulsants, rifampicin, spironolactone and griseofulvin. This may result in lowered efficacy.

Migraine, malabsorption syndrome, smoking and history of liver disease have not been identified as contraindications to mini pills.

This is one of the defects attributable to Carbimazole use.

CA-125 has found application as a tumour marker or biomarker that may be elevated in the blood of some patients with specific types of cancers, or other conditions that are benign. Increased level of CA125 appears in fifty percent of stage 1 ovarian cancer patients and more than 90% with stages 2-4 ovarian cancer. CA-125 is therefore a useful tool for detecting ovarian cancer after the onset of symptoms as well as monitoring response to treatment and for predicting a patient’s prognosis after treatment.

Condylomas are warty neoplasms of the vulvar area. The most common type are condyloma acuminatum which occur due to HPV 6 or 11. Condyloma latum are also known as secondary syphilis are less common. Both of these are sexually transmitted.

Stages of Syphilis:
– Primary 3-90 days
Chancre and lymphadenopathy
– Secondary 4-10 weeks
Widespread rash typically affecting hands and soles of feet.
Wart lesions (condyloma latum) of mucus membranes
– Latent Early <1 yr. after secondary stage
– Late >2 yr. after secondary stage
Asymptomatic
– Tertiary 3+ years after primary infection
Gummas or
Neurosyphilis or
Cardiovascular syphilis

In severe cases of hyperemesis, complications include vitamin deficiency, dehydration, and malnutrition, if not treated appropriately. Wernicke encephalopathy, caused by vitamin-B1 deficiency, can lead to death and permanent disability if left untreated. Additionally, there have been case reports of injuries secondary to forceful and frequent vomiting, including oesophageal rupture and pneumothorax.

Electrolyte abnormalities such as hypokalaemia can also cause significant morbidity and mortality. Additionally, patients with hyperemesis may have higher rates of depression and anxiety during pregnancy.

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.

The placenta accepts the blue, unoxygenated blood from the foetus through blood vessels that leave the foetus through the umbilical cord (umbilical arteries, there are two of them). When blood goes through the placenta it picks up oxygen and becomes red. The red blood then returns to the foetus via the third vessel in the umbilical cord, the umbilical vein. The red blood that enters the foetus passes through the fetal liver and enters the right side of the heart.

The most probable cause of her presentation is a mixed infection with Chlamydia trachoma and vaginal pathogens.

Her most likely diagnosis is pelvic inflammatory disease (PID) as suggested by a purulent vaginal discharge alongside a fever which indicates a systemic infection.

The most common causative organisms in PID after sexual activity are chlamydia and gonorrhoea, of which chlamydia has a much higher prevalence.

Chlamydia has also been shown to be present in about 15% of subjects who underwent pregnancy termination with no constant sexual partner.

PID occurring after a gynaecologic surgical procedure is most commonly a result of mycoplasma or vaginal pathogens.

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.

The normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.

The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.

The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.

As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.

Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.

Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.

An assessment of amniotic fluid in pregnancy can be done by taking ultrasound measurements of the depth of amniotic fluid pockets. The combination of the measurements in four quadrants is called the amniotic fluid index (AFI), one of the major determinants of the biophysical profile which predicts pregnancy outcome. An AFI of less than 5 cm, or less than the 5th percentile is defined as oligohydramnios while an AFI of more than 25 cm is considered polyhydramnios.

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.

The uterus is divisible into two portions. The portion above the isthmus is termed the body, and that below, the cervix. The uterine cervix is the narrow inferior segment of the uterus, which projects into the vaginal cavity. It is a fibromuscular organ lined by a mucous membrane and measures approximately 3cm in length and 2.5cm in diameter. The cervix is continuous at its superior margins with the body of the uterus and at its inferior margins with the vagina.

The partial mole is produced when an egg is fertilized by two sperm producing genotype 69 XXY (triploid). It can also occur when one sperm reduplicates itself yielding the genotypes 92 XXXY (tetraploid) though this is less common The genotype of a complete mole is typically 46 XX (diploid) but can also be 46 XY (diploid)

Ultrasound has emerged as the more accurate method of assessing fetal gestational age, especially in the first trimester. Both transvaginal and transabdominal probe assessments are used to obtain a more accurate measurement of gestational age. Transvaginal is more helpful in first trimester pregnancies.

A transvaginal ultrasound exam should not be performed in a pregnant patient with vaginal bleeding and known placenta previa, a pregnant patient with premature rupture of membranes, and a patient who refuses exam despite informed discussion.

Sonographic assessment within the first 13 weeks and 6 days will provide the most accurate estimate of gestational age. Both transvaginal and transabdominal approaches may be used. However, the transvaginal approach may provide a more clear and accurate view of early embryonic structures. Although the gestational sac and yolk sac are the first measurable markers visible on ultrasound, these poorly correlate with gestational age.

Tranexamic acid is an antifibrinolytic drug which is one of the treatment options in menorrhagia i.e. heavy menstrual bleeding. It acts by binding to the receptor sites on plasminogen thus preventing plasmin from attaching to those receptors thus inhibiting plasminogen activation.

If pharmaceutical treatment is appropriate NICE advise treatments should be considered in the following order:

1. levonorgestrel-releasing intrauterine system (LNG-IUS) provided at least 12 months use is anticipated
2. tranexamic acid or NSAIDs* or combined oral contraceptives (COCs) or cyclical oral progestogens
3. Consider progesterone only contraception e.g. injected long-acting progestogens

*When heavy menstrual bleeding (HMB) coexists with dysmenorrhoea NSAIDs should be preferred to tranexamic acid. Also note NSAIDs and tranexamic are appropriate to use if treatment needed pending investigations.