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.

Turner syndrome is the clinical diagnosis for this patient. Turner syndrome affects women who are lacking all of one X chromosome (45, characterized by X gonadal dysgenesis).
Turner Syndrome is characterized by small stature and non-functioning ovaries, resulting in infertility and lack of sexual development. Other sexual and reproductive organs (uterus and vagina) are normal despite the inadequate or missing ovarian activity.

Webbing of the neck, puffy hands and feet, coarctation of the aorta, and cardiac anomalies are all physical symptoms of Turner Syndrome. Streak gonads are also a feature of Turner syndrome.

The ovaries are replaced with fibrous tissue and do not produce much oestrogen, resulting in amenorrhea.

Until puberty, when oestrogen-induced maturation fails, the external female genitalia, uterus, and fallopian tubes develop normally.

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

Tamoxifen and Raloxifene are drugs which acts as selective estrogen receptor modulators.
Their mechanisms of action are competitive inhibitor of estrogen binding and mixed agonist/antagonist action respectively.
Commonly indicated in prevention of breast cancer in high-risk patients. Tamoxifen as adjuvant treatment of breast cancer and Raloxifene in postmenopausal osteoporosis.
Adverse effects include:
– Hot flashes
– Venous thromboembolism
– Endometrial hyperplasia & carcinoma (tamoxifen only)
– Uterine sarcoma (tamoxifen only)
Adjuvant endocrine therapy is commonly used option for treatment of nonmetastatic, hormone-receptor-positive breast cancer; and the most commonly used endocrine agents include tamoxifen, aromatase inhibitors, and ovarian suppression via GnRH agonists or surgery.

Tamoxifen is a selective estrogen receptor modulator which is an estrogen receptor antagonist in the breast.  It is the most preferred adjuvant treatment for pre-menopausal women at low risk of breast cancer recurrence.  Tamoxifen is also a second-line endocrine adjuvant agent for postmenopausal women who cannot use aromatase inhibitor therapy due to intolerable side effects.
Tamoxifen acts as an estrogen agonist in the uterus and stimulates excessive proliferation of endometrium. Therefore, tamoxifen use is associated with endometrial polyps in premenopausal women, and endometrial hyperplasia and cancer in postmenopausal women. These effects will continue throughout the duration of therapy and resolves once the treatment is discontinued. Even with all these possible complications, benefits of tamoxifen to improve the survival from breast cancer outweighs the risk of endometrial cancer.

In postmenopausal women, tamoxifen has some estrogen-like activity on the bone, which can increase bone mineral density and thereby reduce the incidence of osteoporosis significantly.  However, tamoxifen is generally not a first-line agent for osteoporosis in treatment due to the marked risk of endometrial cancer.

Dysplasia of the cervical transformation zone is typically caused due to chronic infection by human papillomavirus, and tamoxifen has no known effects on the cervix.

Tamoxifen is not associated with any increased risk for adenomyosis, which is characterised by ectopic endometrial tissue in the myometrium.

Intimal thickening of the coronary arteries is a precursor lesion for atherosclerosis. Tamoxifen helps to decrease blood cholesterol level and thereby protect against coronary artery disease.

Tamoxifen is an estrogen antagonist on breast tissue and is used in the treatment and prevention of breast cancer, but it also acts as an estrogen agonist in the uterus and increases the risk of development of endometrial polyps, hyperplasia, and cancer.

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.

WHO guidelines
Semen volume: Greater than or equal to 1.5 ml
pH: Greater than or equal to 7.2
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
Total sperm number: 39 million spermatozoa per ejaculate or more
Total motility (% of progressive motility and nonprogressive motility): 40% or more motile or 32% or more with progressive motility
Vitality: 58% or more live spermatozoa
Sperm morphology (percentage of normal forms): 4% or more

The oocyte (eggs, ova, ovum) is arrested at an early stage of the first meiosis (first meiotic) division as a primary oocyte (primordial follicle) within the ovary. Following puberty, during each menstrual cycle, pituitary gonadotrophin stimulates completion of meiosis 1 the day before ovulation.

Maternal disorders, such as diabetes, in-utero infections, drug usage, placental abnormalities and fetal conditions as congenital and chromosomal abnormalities, Rh iso-immunization, and multiple gestations, are generally associated with polyhydramnios. Congenital abnormalities such as duodenal, oesophageal, or intestinal atresia of the foetus are the most common malformations that typically cause gastro-intestinal obstruction and interfere with fetal swallowing and/or absorption resulting with polyhydramnios. However, in about 70% of cases, none of the aforementioned aetiologies are causes of polyhydramnios, and it is referred to as idiopathic or isolated.

Maternal blood volume expands during pregnancy to allow adequate perfusion of vital organs, including the placenta and foetus, and to anticipate blood loss associated with delivery. The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. While there is some increase in intracellular water, the most marked expansion occurs in extracellular fluid volume, especially circulating plasma volume. This expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Overall, total body water increases from 6.5 to 8.5 L by the end of pregnancy.

The internal anal sphincter is innervated by pelvic splanchnic nerves

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

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.

The risk of uterine perforation is 0.1% during therapeutic hysteroscopy.

Tamoxifen is a SERM that is effective in treating hormone-responsive breast cancer, it acts as an antagonist to prevent receptor activation by endogenous oestrogen. As agonist of the endometrial receptors it promotes endometrial hyperplasia and hence increases the risk of endometrial cancer.

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

Immediately after birth the liver is deprived of the large flow of blood supplied during foetal development via the umbilical vein and portal sinus. Simultaneously the blood pressure in the portal sinus, previously as high as in the umbilical vein, falls.

Postinor-2 (levonorgestrel 750pg) is only an emergency contraceptive and is not designed to be a regular form of contraception. If taken within 24 hours, it is estimated to be able to prevent up 97-98% of pregnancies and 58% if given between 48-72 hours post-unprotected intercourse. It can cause vaginal bleeding within a few days of its administration if it is given before day 8-10 of her menstrual cycle. However, if given mid-cycle, it typically doesn’t affect the timing of her next period unless conception occurs. Nausea and vomiting were common when high doses of OCP were used as a post-intercourse contraceptive. Nausea and vomiting still can occur with Postinor-2, but not up to 50% of women. There is currently no evidence to suggest that the levonorgestrel dose would cause a virilising effect on female foetuses.

Amniotic fluid can be measured with the help of ultrasound to gauge the amniotic fluid index. The normal value ranges between 8-18.
Amniocentesis is a procedure by which amniotic fluid is removed. In rhesus disease, it appears yellow due to raised bilirubin levels.

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

The perineal membrane is a tough fascial sheet that attaches to the sides of the urogenital triangle. it forms the inferior border of the deep pouch which lies between this and the levator ani and the superior border of the superficial pouch.

In an ECG the P wave represents atrial depolarization. The QRS complex represents the ventricular depolarization, T waves represent ventricular repolarization and the U wave represents repolarization of the interventricular septum.

Major vessel injury is the most important potential complication when undertaking laparoscopy. It’s incidence is 0.2/1000. Bowel Injury is more common at 0.4/1000

Ergot alkaloids e.g. Ergometrine, produce marked and prolonged alpha receptor mediated vasoconstriction. Its overdose can cause ischemia and gangrene of the limbs and bowel. It also causes coronary artery spasm and has been used by cardiologist as a provocation test.

Trigeminal nerve has three divisions, the first is the ophthalmic division that does not originate from any of the pharyngeal arches, the second and third divisions, namely, the maxillary and the mandibular region develop from the first pharyngeal arch.
Pharyngeal Arches:
1st = Trigeminal V2 & V3 (CN V)
2nd = Facial (CN VII)
3rd = Glossopharyngeal (CN IX)
4th and 6th = Vagus (CN X)

B-HCG levels almost double every 48 hours. A B-HCG levels of less than 5 mIU/ml is considered negative and anything above 25 is considered positive. As the foetus was not visualized on ultrasound in the uterus, there is possibility that this might be an ectopic pregnancy. But since the B-HCG levels also continued to fall the pregnancy becomes non-viable.

In Cushing’s syndrome there is excess cortisol. Causes are broadly divided into 2 types: ACTH dependent disease: excess ACTH from the pituitary (Cushing’s disease), ectopic ACTH-producing tumours or excess ACTH administration. Non-ACTH-dependent: adrenal adenomas, adrenal carcinomas, excess glucocorticoid administration. The recommended diagnostic tests for the presence of Cushing’s syndrome are 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test and late-night salivary cortisol. There are several other tests that may also be performed to find the cause. ACTH and cortisol measured together may show if this is ACTH dependent or not. MRI pituitary and CT abdo and pelvis may show if tumour is the cause.

Adenomyosis is a disorder characterised by the presence of endometrial glands deep within the myometrium. It presents with increasing severe secondary dysmenorrhoea and increased in the flow of menstrual blood.

The pudendal nerve arises from the S2-S4 nerve roots and it lies medial to the internal pudendal artery while exiting the pelvis via the greater sciatic foramen. It curves around the sacrospinous ligament and re-enters the pelvis via the lesser sciatic foramen and from there it runs medial to the ischial tuberosity over the obturator internus in the pudendal canal to the deep perineal pouch.

Clavulanic acid is a beta-lactamase inhibitor that is most often combined with a penicillin to form Augmentin or Co-amoxiclav for greater antibiotic efficacy. The drug works by irreversibly binding to enzymes present in bacteria which posses the Beta-lactamase enzyme. This enzyme is responsible for inactivating Beta-Lactam antibiotics such as penicillin.

The pelvic outlet is bounded in front by the lower margin of the symphysis pubis, on each side by the descending ramus of the pubic bone, the ischial tuberosity and the sacrotuberous ligament, and posteriorly by the last piece of the sacrum. The AP diameter of the pelvic outlet is 13.5 cm and the transverse diameter is 11 cm.

Vulval intraepithelial neoplasia is a premalignant condition which is associated with HPV or lichen sclerosis. Biopsy is essential for diagnosis. Treatment depends of the patients choice and include surgical excision of the area or laser therapy with CO2. Other treatment modalities include immunomodulating creams.

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

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).

COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.

Nerve Supply: L5 to S2 via Nerve to Piriformis
Origin: Sacrum
Insertion: Greater trochanter
Action: External rotation of hip
Blood Supply: Superior and Inferior gluteal arteries and lateral sacral arteries

Lymph node involvement means that the carcinoma is stage 4. The 5 year survival of stage 4 endometrial carcinoma is 16%.

ALP can rise to up to 3 times the normal non-pregnant value in the 3rd trimester. All of the other tests above typically decrease during pregnancy.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. There are various risk factors for gestational diabetes including increasing age, ethnicity, previous still births etc.

The Conjoint tendon AKA Inguinal falx reinforces the posterior wall of the inguinal canal. The inguinal and lacunar ligaments are part of the floor The aponeurosis of external oblique is the major component of the anterior wall with fibres of internal oblique reinforcing the lateral part

Incontinence in women is typically related to dysfunction of the bladder or pelvic floor muscles, with such dysfunction often arising during pregnancy or childbirth, or at the time of menopause.

A pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women

Prostaglandins are involved in the uterine contraction and cervical dilatation during labour. Higher prostaglandin concentrations can also lead to severe menstrual cramps.

In a postmenopausal woman, the ovaries should not be palpable; if they are, it should raise the concern that an ovarian malignancy is present. Before one would perform an operative evaluation, radiologic assessment should be done.

– Although this is an accepted regimen for oestrogen replacement therapy, the palpable ovaries need to be evaluated to rule out malignancy.
– Dual photon densitometry will give a reliable measure of bone density. Again, however, the palpable ovary is the first thing that needs to be worked up.
– Although surgical exploration may be warranted, initial workup of the adnexal mass should include an ultrasound along with tumour markers. A CT scan may also be warranted.

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.

A cephalic presentation is the one where head of the foetus enters the pelvic cavity at the time of delivery. The commonest form of cephalic presentation is the vertex presentation in which the occiput of the foetus enters the birth canal.

Uterine surgical history & scope of vaginal birth are as follows:
– In case of low transverse cesarean delivery with horizontal incision: trial of labor is not contraindicated.
– Classical cesarean delivery with vertical incision: trial of labor is contraindicated
– Abdominal myomectomy with uterine cavity entry: trial of labor is contraindicated
– Abdominal myomectomy without uterine cavity entry: trial of labor is not contraindicated.

In laboring patients with prior uterine surgical histories like a prior classical (vertical) cesarean delivery or a prior myomectomy that was extensive or has entered the uterine cavity like during removal of intramural or submucosal fibroids are at a higher risk for uterine rupture. Given this patient’s history of previous myomectomy, her intense and constant abdominal pain with an abnormal fetal heart rate tracing, like persistent variable decelerations, are pointing to uterine rupture. vaginal bleeding, abdominally palpable fetal parts, loss of fetal station and any change in contraction pattern are the other possible manifestations of uterine rupture. Based on the extent and exact location of the rupture and the presence or absence of regional anesthesia, presentation of a uterine rupture will change.

Vaginal delivery is safe after a low transverse (horizontal uterine incision) cesarean delivery. Patients with a history of either classical cesarean delivery or an extensive myomectomy are delivered via cesarean delivery at 36-37 weeks gestation, so urgent laparotomy and cesarean delivery are required if these patients present in labor. Further management is determined by other intraoperative findings like, whether uterine rupture has occurred, if occured then delivery is done through the rupture site, followed by a uterine repair; If the uterus is unruptured, a hysterotomy (ie, cesarean delivery) is performed. In patients with prior classical cesarean delivery or extensive myomectomy, an expectant management for a vaginal delivery is contraindicated.

Amnioinfusion is the technique of placing an intrauterine pressure catheter to decrease umbilical cord compression by doing an intrauterine infusion and this thereby helps to resolve variable decelerations. In patients with a history of uterine surgery Amnioinfusion is contraindicated.

In cases with abnormal fetal heart rate tracings, if the patient is completely (10cm) dilated, an operative vaginal delivery can be performed to expedite a vaginal delivery.

Terbutaline is a tocolytic, which is administered to relax the uterus in conditions with contractile abnormalities, such as tachysystole which presents with >5 contractions in 10 minutes or tetanic contractions were contractions last for >2 minutes, which results in fetal heart rate abnormalities. In the given case, the patient’s contractions are normal, which occurs in every 2-3 minutes and lasts for 45 seconds, causing pain and cervical dilation.

After a classical cesarean delivery or an extensive myomectomy, labor and vaginal delivery are contraindicated due to its significant risk of uterine rupture. Laparotomy and cesarean delivery are preferred in laboring a patients at high risk of uterine rupture.

Boundaries of the Femoral Triangle:
Superior: Inguinal ligament
Medial: Medial border of the adductor longus
Lateral: Medial border of the sartorius
Floor: Pectineus, Adductor longus and Iliopsoas muscles
Roof: Fascia Lata

A sample for fetal blood pH can be taken during the labour. The mother should be lying in a left lateral position.

Promethazine or Cyclizine are 1st choice options for management of nausea and vomiting in pregnancy according to NICE. Prochlorperazine is also appropriate 1st line.

The risk factors of endometrial cancer include obesity, diabetes, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of colorectal and ovarian carcinoma.

pre-eclampsia is defined as hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week.

Primary hyperparathyroidism is the most common cause of hypercalcemia. It is usually caused by a tumour of the parathyroid gland. Symptoms are related to increased calcium levels which can cause kidney stones, abdominal groans, psychiatric overtones and bones disease such as osteoporosis,osteomalacia and arthritis.

The role of androgens in the female includes acting as precursors for oestrogen production, anabolic effects, stimulation of axillary and pubic hair growth, sebum production, stimulation of bone formation, and stimulation of erythropoietin production in the kidneys.

Tetracycline is classified as a broad spectrum antibiotic. It is a bacteriostatic inhibitor of protein synthesis acting at the ribosomal level. Tetracycline binds to the 30s ribosomal subunit preventing the binding of the aminoacidic charged T-RNA to the ribosome-mRNA complex.

Women with polycystic ovary syndrome (PCOS) have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed oestrogen that results from anovulation.

Additionally, secretory endometrium of some women with PCOS undergoing ovulation induction or receiving exogenous progestin exhibits progesterone resistance accompanied by dysregulation of gene expression controlling steroid action and cell proliferation.

Other risk factors include nulliparity, early menarche and late menopause, obesity and family history of endometrial cancer. Which rules out all the other options.

Genital herpes can be asymptomatic or have mild symptoms that go unrecognized. When symptoms occur, genital herpes is characterised by one or more genital or anal blisters or ulcers. Additionally, symptoms of a new infection often include fever, body aches and swollen lymph nodes.

HSV-2 is mainly transmitted during sex through contact with genital or anal surfaces, skin, sores or fluids of someone infected with the virus. HSV-2 can be transmitted even if the skin looks normal and is often transmitted in the absence of symptoms.

In rare circumstances, herpes (HSV-1 and HSV-2) can be transmitted from mother to child during delivery, causing neonatal herpes. Neonatal herpes can occur when an infant is exposed to HSV during delivery. Neonatal herpes is rare, occurring in an estimated 10 out of every 100 000 births globally. However, it is a serious condition that can lead to lasting neurologic disability or death. The risk for neonatal herpes is greatest when a mother acquires HSV for the first time in late pregnancy.

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.

Thyroid function in pregnancy is altered in two ways; the circulating levels of the thyroid binding proteins are increased, resulting in an increase in the total circulating levels of thyroid hormones (but a slight fall in the free component).

Diastolic murmurs should be considered pathological until proven otherwise. The following are common and typically benign findings in pregnancy: A third heart sound after mid-pregnancy. Systolic flow murmurs are common. Left axis deviation on ECG is common, Sagging ST segments and inversion or flattening of the T wave in lead III may also occur

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

Chlamydia trachomatis (D-K subtypes) is the most common cause in this age group and fits the descriptors given.