Urethral syndrome is characterized by dysuria and pyuria in the presence of a negative culture for uropathogens. Frequency and urgency are often absent. The infecting organism is typically Chlamydia trachomatis although other organisms such as Urea plasma urealyticum and Mycoplasma species may be involve- Effective medication choices include doxycycline, ofloxacin, levofloxacin, and macrolides such as erythromycin and azithromycin.

-Amoxicillin
lavulanate  and cephalexin  are incorrect. These would cover gram-positive bacteria but it would not cover gram-negative bacteria nor bacteria without a cell wall, which are the most common causes of this condition.
– Metronidazole is best for treating anaerobic infections and protozoa such as trichomonas vaginalis, it would not be the best for treating this condition, given the most likely causes.
-Pyridium is a phenazopyridine often used to alleviate the pain, irritation, discomfort, or urgency caused by urinary tract infections. While it would be beneficial for symptomatic relief, it is unlikely to completely resolve this patient’s condition, given her recent history.

The internal anal sphincter is innervated by the splanchnic nerves. Sympathetic nerve supply from the inferior hypogastric plexus (for contraction) and parasympathetic supply from nervi erigentes (for relaxation).

Reported cure rates for an episode of acute BV vary but have been estimated to be between 70% and 80%. Unfortunately, more than 50% of BV cases will recur at least once within the following 12 months. Because the aetiology of BV is still not entirely understood, identifying the cause of recurrent cases is challenging. Reinfection may play a role in explaining recurrent BV, but
treatment failure is a more likely contributor. There are several theories that try to explain recurrence and persistent symptoms. The existence of a biofilm in the vagina is one such theory and is the subject of ongoing research. Biofilms occur when microorganisms adhere to surfaces. G vaginalis, one of the primary organisms

BV is not a sexually transmitted infection. The antibiotic of choice to treat BV is Metronidazole. Reassurance is not acceptable as a means of treatment.

Beta Thalassaemia is autosomal recessive.

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.

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus. It causes the formation of multiple ossification centres in the long bones. Resulting in stippled epiphyses and hence deform long bones.

This patient has acidosis as the pH is low <7.35 The pO2 is irrelevant. The pCO2 is raised i.e. the respiratory system is causing acidosis. The patient is acidotic so this is a respiratory acidosis The Base Excess is normal. You would typically expect the base excess to rise but metabolic compensation is slower than respiratory compensation so this picture may be seen acutely.

Remember the inferior rectal artery supplies the anus. The middle rectal artery is the principle supply to the lower 1/3 rectum. The rectal arteries do form an anastomosis.

Micturition is defined as a process of expelling urine from the body. It is caused by the reflex contraction of detrusor muscle. Urinary bladder is a hollow muscular organ which can store 400-600ml of urine until it is expelled from the body. The first urge to urinate is felt when the bladder is filled with around 150ml of urine. The reflex action is initiated when the stretch receptors located in the bladder wall are stimulated. The afferent fibres pass to the pelvic splanchnic nerves to the 2nd, 3rd, and 4th sacral segments and some pass through the hypogastric plexus to the first and second lumbar segments of the spinal cord. Efferent pathways from the 2nd, 3rd, and 4th sacral segments leave the cords and through the splanchnic nerves and inferior hypogastric plexus supplies the smooth muscle of the bladder i.e. detrusor muscle. Detrusor muscle contracts and the sphincters are relaxed.

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.

During pelvimetry, the shape of the pubic arch is usually examined. It helps in determining the outcome of the type of fetal delivery.

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.

Oogonium become Primary Oocyte via Growth/Maturation. This process is called oocytogenesis Primary Oocyte undergoes 2 meiotic divisions to become Ootids. This process is called Ootidogenesis Ootids differentiate into Ovum

The given case can be diagnosed as round ligament pain, which is common during pregnancy. This happens as a result to the stretching of round ligament in pelvis to occupy the growing uterus. The round ligament pain usually gets worse with movements or straining and will be relieved by rest or warm application.

As the abdominal examination of patient is unremarkable, conditions like ovarian cyst rupture, ectopic pregnancy and intestinal obstruction are a very unlikely to be the diagnosis.

Warfarin inhibits Vitamin K dependent clotting factors. These include factors 2,7,9 and 10.

MEDIAL umbilical ligament = remnant fetal umbilical arteries
MEDIAN umbilical ligament = remnant of urachus

With increasing maternal age, the risk of miscarriage increases. For women between the ages of 40-44, the miscarriage rates sit at about 50% and increases to over 75% for women 45 years and over. The miscarriage rate for women between the ages of 35-39 is 25%.

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.

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.

If abnormal cells are found high up in the cervical canal, it is critical to consider doing a cone biopsy to rule out any cervical malignancy. A cone-shaped section of the cervix containing the abnormal cells is removed under general anaesthesia.
Loop Electrosurgical Excision Procedure is a way of removing the abnormal cells from the cervix using a wire loop. First a speculum is inserted to open the vagina so the uterus can be seen. Then a solution is applied to the surface of the cervix to make the areas of abnormal cells easier to see. It is done under local anaesthesia.

Cone biopsy is the only acceptable option to rule out malignancy. Cryotherapy, chemotherapy and radiotherapy are management options once malignancy has been confirmed.

Hyperemesis Gravidarum effects around 0.3-2% of Pregnancies. It causes imbalances of fluid and electrolytes, disturbs nutritional intake and metabolism, causes physical and psychological debilitation and is associated with adverse pregnancy outcome, including an increased risk of preterm birth
and low birthweight babies. The aetiology is unknown however various potential mechanisms have been proposed including an association with high levels of serum human chorionic gonadotrophin (hCG), oestrogen and thyroxine.

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.

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

Because of the high possibility of spontaneous resolution and the fact that if the cystic mass was verified ultrasonically, a conservative policy would almost probably be proposed for at least another six weeks, an ultrasound examination is not necessary at this time. If the cyst is still present at the six-week check, an ultrasound examination is required, as it is likely that the cyst is a benign tumour or possibly endometriosis. It’s quite improbable that it’s cancer.
Additional tests, such as computed tomography (CT) examination and potentially surgical removal or drainage, may be required in the future, although not at this time.
This cyst in a young lady is almost probably of physiological origin, especially given its size. The woman should be informed, but a follow-up examination is required. The most suitable next action is to return in six weeks, as the cyst is most likely physiologic and will most likely dissipate naturally by then. The following appointment should not take place during the same menstrual cycle.

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 history is typical of Intrahepatic Cholestasis of Pregnancy, also known as obstetric cholestasis and prurigo gravidarum. It is characterised by itching without rash and abnormal LFTs beyond normal pregnancy ranges. Itching affects around 23% of pregnancies and can occur before biochemical changes.

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.

If the external anal sphincter is in tact then this is a 1st or 2nd degree tear. As the perineal muscles are involved this is 2nd degree tear.

Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.

Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.