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.

This patient who is at her 29 weeks of pregnancy, presented with sudden gush of clear fluid and Speculum examination has confirmed premature rupture of membrane (PROM).

Approximately, 50% of PROM progress to labour within 24 hours and in the remaining, 80% within seven days. The most important next step of management in this case is transferring this patient to tertiary care hospital as soon as possible. It is equally important to give corticosteroid therapy, like Betamethasone, if delivery prior to 34 weeks is likely to occur, as it will help in fetal lung maturity.

Cardiotocography (CTG) is usually not available in general practice settings and it can be done only while in the hospital. If CTG shows any abnormality or if there is any presence of infection it is better to induce labor.

Salbutamol and nifedipine are of no use in this case, as the patient is not in labour and does not require tocolytics.

In pregnancy, term refers to the gestational period from 37 0 to 41 6 weeks. Preterm births occur between 24 0 and 36 6 weeks. 60% of the women will go into labour with in 24 hours in PPROM. After 24 hours have past without any contraction and the gestation age is more than 34 week than prostaglandins can be used to augment labour.

Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

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.

Lymphatic vessels from the vagina drain from the parts of the vagina as follows:
• Superior part: to the internal and external iliac lymph nodes.
• Middle part: to the internal iliac lymph nodes.
• Inferior part: to the sacral and common iliac nodes.

Signs of shoulder dystocia:
– Difficulty with delivery of the face and chin
– The head remaining tightly applied to the vulva or even retracting (turtle-neck sign)
– Failure of restitution of the fetal head
– Failure of the shoulders to descend
Upon identifying shoulder dystocia additional help should be called and McRoberts manoeuvre (flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen) should be performed first. Fundal pressure is associated with uterine rupture and should not be used.

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

The alpha cells in the islets of Langerhans are responsible for the production and secretion of glucagon. The B cells secrete insulin, the D cells secrete somatostatin, and the F cells secrete pancreatic polypeptide. The B cells, which are the most common and account for 60–75% of the cells in the islets, are generally located in the centre of each islet.

Miscarriage is a pregnancy that ends spontaneously before the foetus reaches the age of viability i.e. before 24 weeks of gestation. In a threatened miscarriage the USG findings are of a foetus present in the uterus and on speculum examination the cervical OS is closed, in an inevitable miscarriage the cervical OS is opened. In an incomplete miscarriage the uterus contains the retained products of conception and the cervical OS is open. complete miscarriage contains no retained products of conception and the cervix is closed as the bleeding as resolved.

Passive immunity to the neonate is provided by immunoglobulin G (IgG) since it can be transferred through the placenta from mother to the foetus.
IgA is transferred from mothers to offspring through breast milk.
IgM molecular structure is too big to be filtered through the placental vasculature to the foetus. IgM is the first Ig to be synthesised by the neonate

Tenderness is usually suggestive of a benign breast mass such as a breast abscess. Ultrasound is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage.

If one believes that this cycle will last 35 days, the cyst in the left ovary was discovered at mid-cycle.
It’s too huge to be a ruptured pre-ovulatory follicle, and it doesn’t exhibit the characteristics of a corpus luteum, a benign cystic teratoma, or an endometrioma.

As a result, a follicular cyst is the most likely diagnosis.

A benign cyst is almost always seen on ultrasound as a unilocular, thin-walled cystic formation.

The presence of solid materials in a multiloculated cystic structure strongly suggests the presence of a malignant mass.
In a 25-year-old woman, this would be unusual, but not unheard of.

SPIKES protocol for delivering serious news to patients includes:
– Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
– Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
– Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
– Knowledge:
Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
– Empathy: Express understanding & give support when responding to emotions
– Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.

The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases.  In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal.  When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with.  For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later.  The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.

These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.

This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.

This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.

While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.

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.

The number of stillbirths and deaths in the first week of life per 1000 births.
According to WHO the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.

Normally, there will be a slight raise in prolactin level throughout pregnancy even despite estrogen stimulating and progesterone inhibiting prolactin secretion.

Serum alkaline phosphatase levels will be increased in pregnancy due to placental ALP.

During the first trimester of pregnancy there is a physiological mechanism by hCG causing cross-stimulation of the TSH receptors and as a result of this the concentration of thyroid stimulating hormone (TSH) normally decreases. During second trimester TSH concentration will again return back to its pre-pregnancy levels and then rises slightly by the third trimester. However, most of the changes still occur within the normal non-pregnant range, and the serum free T3 and T4 concentrations remain unchanged throughout pregnancy. But the total concentrations, which include both free and protein-bound fractions, elevates significantly due to an increase in the circulating binding globulins.

Iron binding capacity reflects transferrin, a protein used for iron transportation, which is a globulin found in the beta band on electrophoresis. To counteract the reduction of plasma iron during pregnancy both transferrin and iron binding capacity are elevated during this period.

When compared to the non-pregnant level, cortisol levels are been elevated up to three times than normal.

Diagnostic hysteroscopy with dilatation and curettage (D&C) is the most suitable step for immediate management of this patient (correct answer). This would aid in determining if an endometrial lesion exists and enable histologic examination of any endometrium that may be present.
Assessment of endometrial thickness via ultrasound examination is commonly used to decide if a patient requires D&C. In postmenopausal women, an endometrial thickness of more than 4mm indicates need for D&C.

However, this method is more beneficial in younger postmenopausal women. In women who are 70 years or older, postmenopausal bleeding should be considered to be due to a malignancy until confirmed otherwise.

In this patient, a vaginal swab for culture or a colposcopy would not be appropriate.

Similarly, laparoscopy is not indicated unless the bleeding continued despite a normal hysteroscopy and D&C.

If the endometrial thickness is less than 4mm, a malignancy is less likely to be present; however, the risk cannot be completely excluded.

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

Macrophages are derived from monocytes. When monocytes come across a pathogen they differentiate into macrophages for phagocytosis to occur.

Choriocarcinoma may arise as a complication of gestation or as spontaneous germ cell tumours. As this scenario depicts that the women has previous abortion points to the fact that these may have been molar pregnancies. As choriocarcinoma can arise from a molar pregnancy it can be differentiated from it by the presence of invasion into the uterus and metastasis to the lungs primarily.

The following hormones are excreted from the anterior pituitary gland: TSH, GN, ACTH, LH, FSH, MSH, PRL.
Human chorionic gonadotropin (hCG, or human chorionic gonadotrophin) is a placental hormone secreted by syncitiotrophoblasts during the second week of gestation.

Breech presentation refers to the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first.

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the foetus to turn into the vertex presentation in the third trimester include:
– Mullerian anomalies
– Placentation
– Uterine leiomyoma
– Prematurity
– Aneuploidies and fetal neuromuscular disorders
– Congenital anomalies
– Polyhydramnios and oligohydramnios
– Laxity of the maternal abdominal wall.

Prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in preparation for the production of milk. However, milk is not secreted then, because progesterone and oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins.

The blastocyst hatchs from the Zona Pellucida

Penicillin is the treatment of choice for treating syphilis. For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist. Treatment guidelines recommend desensitization in penicillin-allergic pregnant women, followed by treatment with penicillin. Syphilis in pregnancy is associated with mental retardation, stillbirth and sudden infant death syndrome; therefore it should be treated promptly.

– Data are insufficient to recommend ceftriaxone for treatment of maternal infection and prevention of congenital syphilis.
– Erythromycin and azithromycin should not be used, because neither reliably cures maternal infection or treats an infected foetus.
– Tetracycline and doxycycline are contraindicated in pregnancy and ceftriaxone is much less effective than penicillin.

The levels of evidence range from I-IV:
1a: Systematic reviews (with homogeneity) or metanalysis of randomized controlled trials: highest level of evidence.
1b: Individual randomized controlled trial (with narrow confidence interval)
1c: All or none randomized controlled trials
2a: Systematic reviews (with homogeneity) of cohort studies
2b: Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
2c: Outcomes Research; ecological studies
3a: Systematic review (with homogeneity) of case-control studies
3b: Individual case-control study
4: Case series (and poor quality cohort and case-control studies)
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

The proximal portion of urethra in females or membranous urethra in males is in the deep perineal pouch

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.