Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

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.

As they respond differently to different drugs, a thorough distinguishing must be done between the two major groups of epilepsies while approaching a woman, who wishes to become pregnant while on antiepileptic drugs.

Partial epilepsies will respond to most of the antiepileptic drugs, but in case of idiopathic generalized epilepsies, especially in juvenile myoclonic epilepsy, seizure can be controlled only with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful but substitution of sodium valproate with lamotrigine is not the right choice. This is because lamotrigine is not as effective as sodium valproate and will sometimes worsens myoclonic seizures in juvenile myoclonic epilepsy.

Topiramate and levetiracetam are found to be effective in idiopathic generalized epilepsy, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially in myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there will be no effective alternative to sodium valproate as cessation of sodium valproate will lead to recurrence of the generalized seizures, especially juvenile myoclonic epilepsy. Hence, it is not advisable to discontinue the drug in auch patients.

On the other hand, sodium valproate have the highest reported teratogenicity potential among antiepileptic drugs and the Australian Pregnancy Register has reported the risk to be as high as 16% if used in first trimester. Sodium valproate should be avoided in women of reproductive age and if a patient on the medication is willing to become pregnant, she should be well informed about the risk of teratogenicity and the decision must be left to her. If she decides to accept the risks and continue with pregnancy, the lowest possible effective dose should be prescribed to her.

If the dose of sodium valproate has been reduced to minimum during pregnancy to reduce the possible teratogenesis, it is recommended to re-establish the prepartum effective dose before the onset of labor. This is because, it is the time with increased risk for seizures, especially in patients with idiopathic generalised epilepsy who are very sensitive to sleep deprivation. Valproate therapy is found to be safe during breastfeeding.

Before considering invasive procedures, a cervical smear must first be performed. Antibiotics can only be given when inflammation has been confirmed and culture results have identified the organism causing the inflammation. Endometrial ablation, colposcopy and vaginal US are all invasive procedures that are not relevant in the immediate management of this patient.

At 12 weeks gestation the fundus is expected to be palpable above the pubis symphysis and it is expected to be felt at the level of umbilicus by 20 weeks. Though the uterine fundus stands in between from 12 and 20 weeks, the height of the fundus in centimeters is equivalent to the weeks of pregnancy after 20 weeks.

For 14-week pregnant uterus a fundal height of 18cm is definitely large and dating errors is considered as the most common cause for such a discrepancy. Hence, it is better to perform an ultrasound scan for more accurately estimating the gestational age. Also if the case is not a simple dating error, ultrasonography can provide definitive additional information about other possible conditions such as polyhydramnios, multiple gestation, etc that might have led to a large-for-date uterus.

A large-for-gestational-age uterus are most commonly found in conditions like:
– Dating errors which is the most common cause
– Twin pregnancy
– Gestational diabetes
– Polyhydramnios
– Gestational trophoblastic disease, also known as molar pregnancy

The Rhesus status of a mother is important in pregnancy and abortion. The exposure of an Rh-negative mother to Rh antigens from a positive foetus, will influence the development of anti-Rh antibodies. This may cause problems in subsequent pregnancies leading to haemolysis in the newborn. Rh Anti RhD- globulin is therefore given to non-sensitised Rh-negative mothers to prevent the formation of anti-Rh antibodies within 72 hours following abortion. Anti RhD globulin is not useful for already sensitized, or RhD positive mothers.

During pregnancy cardiac output increases by 30 to 50%. As a result, the resting pulse speeds up from a normal of about 70 bpm to 80 or 90 bpm.

There are no interactions between the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone injections or levonorgestrel implants and the AEDs valproic acid (sodium valproate), vigabatrin, lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide, ethosuximide and the benzodiazepines. So she can use COCP along with Sodium valproate.

A fundal height measurement is typically done to determine if a baby is small for its gestational age. The measurement is generally defined as the distance in centimetres from the pubic bone to the top of the uterus. The expectation is that after week 24 of pregnancy the fundal height for a normally growing baby will match the number of weeks of pregnancy — plus or minus 2 centimetres.

A fundal height that measures smaller or larger than expected — or increases more or less quickly than expected — could indicate:
– Slow fetal growth (intrauterine growth restriction)
– A multiple pregnancy
– A significantly larger than average baby (fetal macrosomia)
– Too little amniotic fluid (oligohydramnios)
– Too much amniotic fluid (polyhydramnios).

Nausea and vomiting experienced in 80% of pregnancies Hyperemesis gravidarum (HG) is an extreme form of nausea and vomiting which affects around 1.5% of women. Caused by high levels HCG. Definitions vary but most consider it to be defined by severe nausea and vomiting associated with weight loss greater than 5% of pre-pregnancy weight with metabolic disturbance (typically dehydration and/or ketosis).

Nausea, fatigue, breast tenderness, and increased frequency of urination are the most common symptoms of pregnancy, but their presence is not considered definitive as they are nonspecific symptoms which are not consistently found in early pregnancy, also these symptoms can occur even prior to menstruation.

In pregnancy a physical examination will reveal an enlarged uterus which is more boggy and soft, but these findings are not apparent until after 6th week of gestation. In addition, other conditions like adenomyosis, fibroids, or previous pregnancies can also result in an enlarged uterus which is palpable on physical examination.

An abdominal ultrasound will not demonstrate a gestational sac until a gestational age of 5 to 6 weeks, nor will it detect an ectopic pregnancy soon after a missed menstrual period, therefore it is not indicated in this patient.

A Doppler instrument will detect fetal cardiac action usually after 10 weeks of gestation.

A sensitive serum quantitative pregnancy test can detect placental HCG levels by 8 to 9 days post-ovulation and is considered as the most appropriate next step in evaluation of this patient.

In the period immediately after the delivery of the placenta, known as the puerperium, the female reproductive system begins to undergo some physiological changes to return to a non-pregnant state. One of these changes is uterine involution. The myometrium contracts, constricting blood vessels which impedes blood flow. It is thought that the uterine tissues then undergo apoptosis and autophagy. It takes about 4-6 weeks for the uterus to decrease is size from about 1 kg to 60 grams.

Gestational trophoblastic disorder is characterized by an abnormal trophoblastic proliferation and include a complete and partial mole. It is characterized by persistently elevated BHCG levels after pregnancy and on ultrasound a snow storm appearance. These appear as anechoic areas on ultrasound.

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.

According to NICE guidelines women with type I diabetes, who are expecting a child should aim to keep their HbA1c level[1] below 48 mmol/mol (6.5%) without causing problematic hypoglycaemia. Women with diabetes whose HbA1c level is above 86 mmol/mol (10%) should be strongly advised not to get pregnant because of the associated risks. The risks are higher with chronic diabetes. There is an increased risk to the foetus or mother due to diabetes in pregnancy. Women who are waiting to become pregnant should take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.

Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma’s) sometimes called myoma’s.

Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood distributed to the intervillous spaces of the placentae, and 20 per cent to the uterine myometrium.

Afterpains may continue for 2-3 days (so none of the above). Breastfeeding may intensify pain due to stimulation of Oxytocin which causes uterine contractions

The production of milk is regulated by the hormone Prolactin. Oxytocin on the other hand is responsible for the let down reflex that occurs during breast feeding.

This question is about the differential diagnoses that should be considered if a patient presents with postpartum fever. The work-up for such patients would usually involve vaginal swabs, midstream urine culture and sensitivity and an ultrasound scan of the wound to look for any presence of a haematoma. LSCS is a major surgery and one common cause of puerperal fever would be surgical site infection. It is not surprising that women who deliver via LSCS are at higher risk of developing post-partum fever compared to those who deliver vaginally. Other common causes include endometritis and UTI. Ultrasound examination of the pelvic deep venous system and the legs would also be done to look for any thrombosis. Deep vein thrombosis can occur due to immobility, however it is unlikely to present with fever.

Bicornuate uterus is associated with an increased chance of urinary tract anomalies. Urinary tract anomalies were present in about 23.6% of cases of bicornuate uterus patients.

Luteo-placental shifts occurs around 6-8 week when the placenta takes over from the corpus luteum as the main producer of oestrogen and progesterone.

The woman’s blood pressure was elevated at her visit; therefore she should be advised to immediately cease the oral contraceptive pill (OCP) so that the hypertension can resolve without the need for any hypotensive treatment. The blood pressure can then be reassessed in three months. Alternative, non-hormonal birth control methods such as condoms should be used instead.

If her high blood pressure does not resolve, any medication that would be commenced to reduce her blood pressure should be one that is safe to continue when she becomes pregnant.

It is inappropriate to continue the OCP even at a lower dosage or in combination with a hypotensive agent.

Methyldopa has been evaluated and used for treatment of hypertension during pregnancy. There is no clinical evidence to suggest that it causes harm to the foetus or neonate.

Angiotensin converting enzyme (ACE) inhibitors are not approved for use in pregnancy as they have been associated with fetal death in utero. Other antihypertensive agents such as beta-blockers and diuretics are also problematic in pregnancy and should be avoided.

The progestogen-only pill (POP) is a contraceptive option for women who have high blood pressure either induced by use of combined oral pills or due to other causes; as long as it is well controlled and monitored. Combined oral contraception (COC) and Depo-Provera have been implicated in increased cardiovascular risk following use. High blood pressure has been theorized to be the critical path that leads to this increased risk. POP is the recommended method for women who are at risk of coronary heart disease due to presence of risk factors like hypertension.

Stopping OCP will risk in the patient getting pregnant. Cessation of oestrogen usually reverses the blood pressure back to normal, Hence, all other options are incorrect.

Trichomoniasis is a common sexually transmitted infection caused by a parasite. In women, trichomoniasis can cause a foul-smelling vaginal discharge which might be white, grey, yellow or green, genital itching and painful urination.

Androgen insensitivity syndrome means that patients are phenotypically males but they are resistant or insensitive to male androgen hormones. They do not have a uterus. Due to insensitivity to androgens these patients often have female traits but their genetic makeup is of male, 46XY.

Clinical decision making which contraceptive regimen is optimal for an individual woman with epilepsy is one of the most challenging tasks when taking care of women with epilepsy. The bidirectional interactive potential of antiepileptic drugs (AEDs) and hormonal contraceptives needs to be taken into account. Enzyme inducing (EI)-AEDs may reduce the contraceptive efficacy of hormonal contraceptives.

If combined oral contraceptives (COCs) are used in combination with EI-AEDs, it is recommended to choose a COC containing a high progestin dose, well above the dose needed to inhibit ovulation, and to take the COC pill continuously (“long cycle therapy”). But even with the continuous intake of a COC containing a higher progestin dose contraceptive safety cannot be guaranteed, thus additional contraceptive protection may be recommended.

Progestin-only pills (POPs) are likely to be ineffective, if used in combination with EI-AEDs.

Subdermal progestogen implants are not recommended in patients on EI-AEDs, because of published high failure rates.

Depot medroxyprogesterone-acetate (MPA) injections appear to be effective, however they may not be first choice due to serious side effects (delayed return to fertility, impaired bone health).

The use of intrauterine devices is an alternative method of contraception in the majority of women, with the advantage of no relevant drug–drug interactions. The levonorgestrel intrauterine system (IUS) appears to be effective, even in women taking EI-AEDs. Likelihood of serious side effects is low in the IUS users.

Repetitive late decelerations can be caused by fetal hypoxia which results in constriction of the vessels to circulate blood from the peripheries to more important organs of the body like the brain and heart etc.

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.