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.

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.

The maximum dose of lidocaine with adrenaline is 7mg/kg.

Since the car crash happened two weeks prior, breast trauma is suggested and thus fat necrosis is the most probable diagnosis. Phyllodes tumours are typically a firm, palpable mass. These tumours are very fast-growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50, prior to menopause.

Progesterone gradually increases during the course of pregnancy, from 25 ng⋅mL−1 at 6 weeks’ to 150 ng⋅mL−1 at 37 weeks’ gestation. Progesterone acts as trigger of the primary respiratory centre by increasing the sensitivity of the respiratory centre to carbon dioxide, as indicated by the steeper slope of the ventilation curve in response to alveolar carbon dioxide changes. Progesterone alters the smooth muscle tone of the airways resulting in a bronchodilator effect. It also mediates hyperaemia and oedema of mucosal surfaces, causing nasal congestion.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

Prothrombin time is increased in:
– Factor V deficiency
– Vitamin K deficiency (which affects factors 2,7 and 10)
– Warfarin therapy
– Severe liver failure
Protein C is an anticoagulant and deficiency results in a hyper-coagulable state with tendency towards thrombosis.

Fetal position and presentation is best evaluated by Leopold’s manoeuvre. It will determine which part of the foetus is in the uterine fundus.
Cullen’s sign is found in ruptured ectopic pregnancy characterised by bruising and oedema of the periumbilical region.
Mauriceau-Smelli-Veit manoeuvre is done during a breech delivery.

Clomiphene citrate is widely used in the induction of ovulation, especially in the treatment of anovulatory infertility and in conditions such as PCOS. The drug functions as a selective oestrogen receptor modulator, which acts in the hypothalamus to indicate low serum oestrogen levels. Reduced levels of negative feedback stimulate the secretion of GnRH from the hypothalamus, which in turn stimulate the production of gonadotropins (FSH and LH) from the anterior pituitary. These work to increase ovarian follicular activity.

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

Taking into consideration that she had only missed one pill and that they were going to be stopped the next day anyway, the rate of pregnancy would be low; hence all of the responses would be acceptable and effective. However, the most appropriate step would be to initiate her hormone-free interval starting from the time she missed her pill i.e. 11pm the night before. This would make tonight the 2nd lactose pill day and hence she should commence the next course of hormone pills on the 5 nights from tonight. In doing this, her hormone-free period would be the usual length of 7 days. Although the risk of pregnancy is low after missing only one pill, this opposite occurs when the missed pill causes a longer than normal hormone-free duration between the end of the current cycle and the starting of the subsequent one.

Promethazine is type of antihistamine that acts on the H1 receptor. In pregnancy NICE guidelines advise oral promethazine or oral cyclizine should be used as 1st line drug management of nausea and vomiting. Both are H1 antagonists.

Clotting factor problem. Some of the more common disorders of coagulation that occur during pregnancy are von Willebrand disease, common factor deficiencies, platelet disorders and as a result of anticoagulants.

Obligate anaerobes are a group of bacteria that cannot survive in an oxygen-rich environment. In the body, they are usually found on mucosal membranes such as that of the lower gastrointestinal system, or the vagina. Infection with these organisms is usually suprative and causes abscesses. Examples of gram-negative anaerobes include Bacteroides, Fusobacterium and Prevotella, while gram-positive anaerobes include Actinomyces and Clostridia. Staphylococcus and Streptococcus are both gram-positive facultative anaerobes.

Genetically, patients suffering from androgen insensitivity syndrome are 46XY. They are males but insensitive to male hormones i.e. androgens.

The best regimen would be to have no intercourse in the follicular phase of the cycle and then commence it two days after a temperature rise of 0.3C and continue then onwards. When deciding the best contraceptive method, one has to consider two factors-the duration of survival of sperm in the uterus and body temperature in relation to ovulation. For this case, since her cycle length varies from 24 to 30 days, the earliest time in which ovulation would occur would be 14 days before her shortest cycle i.e. day 10. Intercourse has to be avoided from day 4 of her cycle just in case the current cycle is short because sperm can survive up to 6 days in the uterus. Day 4 would be the day her menses would end and as this couple avoids intercourse during her menstruation, there would be no intercourse during the follicular phase of her cycle.

During ovulation, her serum progesterone levels would start to increase, causing a 0.3°C to 0.4°C increase in her body temperature within 2-3 days of ovulating. This elevation in temperature would remain until close to when her period starts. The ovum can only be fertilised for roughly 24 hours after ovulation has taken place. Resuming sexual intercourse once her temperature has risen for 2 days would suggest that ovulation had already taken place 3-4 days earlier and so it is unlikely for pregnancy to occur.

Options that include intercourse during any part of her follicular phase is not correct. Hence, the only option that satisfies the above criteria would be intercourse avoidance during her follicular phase and to resume 2 days following a rise of 0.03°C in body temperature.

Turner syndrome patients have malfunctioning or streak ovaries due to which they can never conceive. It affects females, who will have a short stature, widely spaced nipples, webbed neck and karyotyping shows 45XO.

Klinefelter syndrome is associated with testicular atrophy, eunuchoid body shape, tall, long extremities, female hair distribution and gynaecomastia. It is a common cause of hypogonadism seen during fertility workup.

Ladd’s bands are the most common form of peritoneal bands in malrotation of the intestine.

The female pelvic inlet tilts at an inclination that is about 60 degrees from the anatomical horizontal plane. This tilt is maintained by muscles and fascia. The pelvic outlet slopes at an angle of 15 degrees.

The case presented points to a diagnosis of an autoimmune thyroiditis leading to hypothyroidism. The most common form of autoimmune hypothyroidism, Hashimoto’s, often presents with a goitre, positive for antibody tests against thyroid components i.e. anti-TPO and anti-thyroglobulin. Graves disease and toxic diffuse goitre are more likely to cause hyperthyroidism. While De-Quervain’s and endemic goitre may cause hypothyroidism, they don’t result in positive antibody tests.

Lymphatic drainage of the breast.
The lateral two thirds of the breast drains into the axillary lymph nodes. This constitute about 75% of the lymphatic drainage of the breast. The medial third of the breast drains into the parasternal lymph nodes and these communicate with the ipsilateral lymph nodes from the opposite breast. The superior part of the breast drains into the infraclavicular lymph nodes and inferior part drains into the diaphragmatic lymph nodes.

The given case where the patient presents with sudden abdominal pain, cessation of uterine contraction and the urge to push along with vaginal bleeding is typical for uterine rupture. Examination shows a decreased or lost fetal heart rate, along with signs of fluid collection including fluid thrill and shifting dullness due to the entry of blood into the peritoneal cavity.
Other common manifestations of uterine rupture include:
– Loss of the station of the fetal presenting part
– Vaginal bleeding which is not be proportionate to the hemodynamic status
-Maternal tachycardia and hypotension ranging from subtle to severer shock
– Uterine tenderness
– Change in uterine shape and contour
– Easily palpable fetal parts
– No fetal presentation on vaginal examination
– Hematuria if the rupture extends to the bladder
Anterior lower transverse segment is the most common site of spontaneous uterine rupture.

Placenta previa usually presents as painless vaginal bleeding, which rules it out as the diagnosis in given case.

Vaginal bleeding with a tender and tense uterus is the presentation in placental abruption, also contrary to uterine rupture, uterine contractions will continue in case of placental abruption.

Cervical laceration can be a possibility, but in such cases more amount of vaginal blood loss was expected in this patient with hemodynamic instability. Also symptoms like deformed uterus, abdominal distention and cessation of contractions are inconsistent with cervical laceration.

Excessive generation of thrombin and fibrin in the circulating blood results in Disseminated intravascular coagulation (DIC) which leads to increased platelets aggregation and consumption of coagulation factors resulting in consequent bleeding at one site and thromboembolism at another. Placental abruption and retained products of conception in the uterine cavity are the most common obstetric causes of DIC. The condition will not fit as diagnosis in this clinical scenario.

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.

When symptoms are present, they may include abdominal pain, mass or swelling, and abnormal uterine bleeding. Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent. When abdominal pain is present, it usually is constant and ranges from slight to moderate in intensity.

Mucinous cystadenomas are relatively common (12% to 15% of all ovarian tumours). They can become massive. These tumours usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence.

Corpus luteal cysts present with irregular menses, abdominal fullness due to fluid build up and pelvic pressure.

Endometriosis mainly presents with cyclic pain at site of involvement and dysmenorrhea.

The five year survival of stage 1 ovarian cancer is 70-90%

A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.

A Bicornuate uterus (heart shaped) is the result of abnormal fusion and reabsorption of the paramesonephric ducts during embryogenesis. Mullerian agenesis typically results in failure to form a uterus. Mullerian duct fusion abnormalities can cause a bicornuate malformation. PKD-1 gene abnormalities are associated with PCOS. Crossed fused ectopia result in Horseshoe kidney.

Serous tumours of the ovaries are large, cystic and spherical to ovoid in shape. They can be benign or malignant. Malignant tumours are usually nodular with irregularities in the surface where the tumour penetrates into the serosa. Psammoma bodies are a histological identification for these tumours which appear in the tips of the papillae.

The treatment of Chlamydia includes avoidance of intercourse, use of condoms and antibiotic treatment. Erythromycin 500mg orally QID for 7 days or Amoxicillin 500mg TDS for 7 days or Ofloxacin 200mg orally BD for 7 days.