A fibroid is a benign smooth muscle tumour or Leiomyoma. As such it is something of a misnomer. Leiomyosarcoma and Angioleiomyoma are malignant tumours of smooth muscle under the WHO sort tissue tumour classification Rhabdomyoma is a skeletal muscle tumour Myofibroma is seen in fibromatosis

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.

Proteinuria of more than 1+ on dipstick should be investigated to quantify the amount of proteinuria. A protein: creatinine ratio can be used to determine the severity of proteinuria, where levels of more than 30 mg/mmol indicate significant proteinuria.

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.

Antepartum haemorrhage presents with bleeding, which may or may not be accompanied by pain. Uterine irritability would suggest abruptio, however contractions are present which may be confused with uterine irritability and in this case, there are no signs of pre-eclampsia present.

Urinary incontinence can be divided into two main aetiologies, stress incontinence, or overactive bladder. Conservative management include lifestyle interventions, controlling fluid intake, or bladder exercises. If conservative management is no longer efficient, then medications may be indicated. Oxybutynin is an anticholinergic drug used in the treatment of urinary incontinence. As with other anticholinergic drugs, side effects include dry mouth, dry eyes, blurry vision and constipation. About 1 in 10 patients taking Oxybutynin will experience some of these side effects.

A fibroid is a benign tumour of the smooth muscles of the uterus also known as a leiomyoma. It has a typical whorled appearance and this may be altered following degeneration which occurs in four main types:
1. Red degeneration, also known as carneous degeneration, of degeneration that can involve a uterine leiomyoma. While it is an uncommon type of degeneration, it is thought to be the most common form of degeneration of a leiomyoma during pregnancy. Red degeneration follows an acute disruption of the blood supply to the fibroid during growth typically in a mid-second trimester presenting as sudden onset of pain with tenderness localizing to the area of the uterus along with pyrexia and leucocytosis. On ultrasound it can have peripheral (rim).

2. Hyaline degeneration is the most common form of degeneration that can occur in a uterine leiomyoma. It is thought to occur in up to 60% of uterine leiomyomasoccurs when the fibroid outgrows its blood supply. this may progresses to central necrosis leaving a cystic space in the centre knowns as cystic degeneration.

3. Cystic degeneration is an uncommon type of degeneration that a uterine leiomyoma (fibroid) can undergo. This type of degeneration is thought to represent ,4% of all types of uterine leiomyoma degeneration. When the leiomyoma increases in size, the vascular supply to it becomes inadequate and leads to different types of degeneration: hyaline, cystic, myxoid, or red degeneration. Dystrophic calcification may also occur. Hyalinization is the commonest type of degeneration. Cystic degeneration is an extreme sequel of edema. Ultrasound may show a hypoechoic or heterogeneous uterine mass with cystic areas.

4. Myxoid degeneration of leiomyoma is one of the rarer types of degeneration that can occur in a uterine leiomyoma. While this type of degeneration is generally considered rare, the highest prevalence for this type of degeneration has been reported as up to 50% of all degenerations of leiomyomas. Fibroids (i.e. uterine leiomyomas) that have undergone myxoid degeneration are filled with a gelatinous material and can be difficult to differentiate from cystic degeneration; however, they typically appear as more complex cystic masses. They appear hypocellular with a myxoid matrix.

Abruptio placentae, defined as a premature separation of the placenta from the uterine wall, is commonly seen with blunt abdominal trauma and can cause fetal distress. It occurs in 1% to 3% of pregnant women with minor trauma and in 40% to 50% with major life-threatening trauma.8,9 Abruption may present with vaginal bleeding, abdominal pain and tenderness, uterine contractions, or fetal distress; however, it may be occult with no vaginal bleeding in up to 20% of cases.

About 1 in 4 pregnant women carry GBS bacteria in their body. Doctors should test pregnant woman for GBS bacteria when they are 36 through 37 weeks pregnant.

Giving pregnant women antibiotics through the vein (IV) during labour can prevent most early-onset GBS disease in newborns. A pregnant woman who tests positive for GBS bacteria and gets antibiotics during labour has only a 1 in 4,000 chance of delivering a baby who will develop GBS disease. If she does not receive antibiotics during labour, her chance of delivering a baby who will develop GBS disease is 1 in 200.

Pregnant women cannot take antibiotics to prevent early-onset GBS disease in newborns before labour. The bacteria can grow back quickly. The antibiotics only help during labour.

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.

Post coital literally means “after intercourse” which is when this fertility test is conducted. The patient has intercourse at home usually between cycle days 12 and 15 (or a day around the LH surge as measured by urinary ovulation predictor kits). Afterwards, the female comes to the office and a sample of the cervical mucus is taken for microscopic examination.

The post coital fertility test (PCT) allows for evaluation of sperm in the cervical mucus and to determine the consistency of the mucus. Sperm must swim through the cervical mucus from the vagina, through the cervix, and into the uterus. Normal sperm will be active and swim in approximate straight lines through the mucus. If the mucus is too thick, sperm impedance can be observed.

CAH leads to virilization of the female foetus. It occurs to an enzyme deficiency (21-hydroxylase). This results in a reduced levels of corticosteroids from being circulated resulting in hyperplasia of the adrenal glands and increased progesterone production. The CYP21A gene has been implicated in causes this deficiency.

Breast infections can be associated with superficial skin or an underlying lesion. Breast abscesses are more common in lactating women but do occur in nonlactating women as well.

The breast contains breast lobules, each of which drains to a lactiferous duct, which in turn empties to the surface of the nipple. There are lactiferous sinuses which are reservoirs for milk during lactation. The lactiferous ducts undergo epidermalization where keratin production may cause the duct to become obstructed, and in turn, can result in abscess formation. Abscesses associated with lactation usually begin with abrasion or tissue at the nipple, providing an entry point for bacteria. The infection often presents in the second postpartum week and is often precipitated in the presence of milk stasis. The most common organism known to cause a breast abscess is S. aureus, but in some cases, Streptococci, and Staphylococcus epidermidis may also be involved.

The patient will usually provide a history of breast pain, erythema, warmth, and possibly oedema. Patients may provide lactation history. It is important to ask about any history of prior breast infections and the previous treatment. Patients may also complain of fever, nausea, vomiting, purulent drainage from the nipple, or the site of erythema. It is also important to ask about the patient’s medical history, including diabetes. The majority of postpartum mastitis are seen within 6 weeks of while breast-feeding

The patient will have erythema, induration, warmth, and tenderness to palpation at the site in question on the exam. It may feel like there is a palpable mass or area of fluctuance. There may be purulent discharge at the nipple or site of fluctuance. The patient may also have reactive axillary adenopathy. The patient may have a fever or tachycardia on the exam, although these are less common.

Incision and drainage are the standard of care for breast abscesses. If the patient is seen in a primary care setting by a provider that is not comfortable in performing these procedures, the patient may be started on antibiotics and referred to a general surgeon for definitive treatment. Needle aspiration may be attempted for abscesses smaller than 3 cm or in lactational abscesses. A course of antibiotics may be given before or following drainage of breast abscesses.

This woman who is 26 weeks pregnant, has come in contact with a child having chickenpox 48 hours ago. As her IgG antibodies were negative during prenatal testing, she has no immunity against Varicella which makes her susceptible to get chickenpox.

Prophylactic treatment is required if a susceptible pregnant woman is exposed to chickenpox, which includes administration of varicella zoster immune globulin (VZIG), within 72 hours of exposure to infection.

As the patient has already checked for and was found to be negative, checking IgG level again is not relevant. Also, it was already revealed that she is not vaccinated against varicella before pregnancy.

If the patient had any symptoms typical of chickenpox, measuring IgM would have been helpful, but patient is completely asymptomatic in this case so measuring IgM is not indicated.

Vaccine for chickenpox is contraindicated during pregnancy as it is a live vaccine.

The Rotterdam criteria for the diagnosis of PCOS is based on a score of two out of the three criteria:
1) Oligo or anovulation
2) Hyperandrogenism – clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
3) on ultrasound – contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 cm3 or greater.

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%.

Hormones that increase during pregnancy and their roles:

1. Human Chorionic Gonadotropin (hCG): Peaks between the eighth to tenth weeks of gestation and supports the corpus luteum to maintain progesterone production.
2. Progesterone: Initially produced by the corpus luteum and later by the placenta, it rises steadily throughout pregnancy, suppressing the maternal immune response to fetal antigens and preparing the endometrium for implantation.
3. Estrogen: Produced by the placenta from fetal and maternal precursors, estrogen levels increase to promote uterine growth and blood flow.
4. Human Placental Lactogen (hPL): Rises significantly during pregnancy, influencing maternal metabolism by increasing insulin resistance and promoting lipolysis.
5. Relaxin: Increases early in pregnancy to relax the uterine muscles, inhibit contractions, and prepare the cervix and pelvis for childbirth.
6. Prolactin: Levels increase to prepare the breasts for lactation.
7. Corticotropin-Releasing Hormone (CRH): Increases towards the end of pregnancy and is involved in the timing of labor.
8. Adrenocorticotropic Hormone (ACTH): Levels increase, contributing to elevated cortisol levels during pregnancy.
9. Total Thyroxine (T4): Levels increase due to elevated thyroid-binding globulin (TBG) production stimulated by increased estrogen levels, meeting the increased metabolic demands of pregnancy.
10. Parathyroid Hormone (PTH): Levels increase to regulate calcium metabolism, ensuring adequate calcium for fetal bone development.
11. Cortisol: Levels increase due to higher production by the adrenal glands and increased binding to cortisol-binding globulin (CBG), supporting glucose metabolism, managing stress, and aiding fetal development, particularly lung maturation.

During pregnancy, some hormones either remain stable or do not increase significantly. These include:

1. Follicle-Stimulating Hormone (FSH): Levels decrease due to the negative feedback from high levels of estrogen and progesterone.
2. Luteinizing Hormone (LH): Levels also decrease due to negative feedback from elevated estrogen and progesterone.
3. Growth Hormone (GH): Although a variant of growth hormone (hGH-V) is produced by the placenta and increases, the maternal pituitary GH levels may not significantly increase.
4. Melatonin: Generally remains stable during pregnancy, though some studies suggest there may be slight fluctuations.
5. Insulin: While insulin resistance increases due to hPL and other factors, the actual levels of insulin may not increase proportionally; instead, pancreatic beta-cell function adapts to meet the increased demand.

Pruritus of pregnancy is a common disorder, which occurs in 1 in 300 pregnancies, and presents as excoriated papules on extensor limbs, abdomen
and shoulders. It is more common in women with a history of atopy. Prurigo usually starts at around 25–30 weeks of pregnancy and resolves after delivery,
with no effect on the mother or baby. Treatment is symptomatic with topical steroids and emollients. It occurs due to derangement in the LFTs. 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.

Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. 

The incidence of listeria infection in pregnant women is estimated at 12 per 100 000 compared to 0.7 per 100 000 in the general population.

Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and oestrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis. A woman is diagnosed with polycystic ovaries (as opposed to PCOS) if she has 20 or more follicles in at least 1 ovary. The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following:
Hirsutism
Infertility
Obesity and metabolic syndrome
Diabetes
Obstructive sleep apnoea

Drugs used in the treatment of polycystic ovarian syndrome (PCOS) include metformin (off-label use), spironolactone, eflornithine (topical cream to treat hirsutism), and oral contraceptives. Oral contraceptives containing a combination of oestrogen and progestin increase sex hormone–binding globulin (SHBG) levels and thereby reduce the free testosterone level. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels are also suppressed. This restores cyclic exposure of the endometrium to oestrogen-progestin, with the resumption of menstrual periods and decreased hirsutism.

Drug of choice for treatment of PCOS are COCs, all other options are incorrect.

The venous drainage of the uterus is via the uterine veins which form a plexus passing below the artery within the base of the broad ligament communicating with the rectal and the vesical venous plexus before draining into the internal iliac veins.

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.

Condylomas are warty neoplasms of the vulvar area. The most common type are condyloma acuminatum which occur due to HPV 6 or 11. Condyloma latum are also known as secondary syphilis are less common. Both of these are sexually transmitted.

Stages of Syphilis:
– Primary 3-90 days
Chancre and lymphadenopathy
– Secondary 4-10 weeks
Widespread rash typically affecting hands and soles of feet.
Wart lesions (condyloma latum) of mucus membranes
– Latent Early <1 yr. after secondary stage
– Late >2 yr. after secondary stage
Asymptomatic
– Tertiary 3+ years after primary infection
Gummas or
Neurosyphilis or
Cardiovascular syphilis

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.

The management of low-grade squamous intraepithelial lesions (LSIL) on cervical cytology in women ages 25 years or older depends upon whether the patient underwent high-risk human papillomavirus (HPV) testing.

Women in this age group comprise two different populations in terms of cervical cancer screening strategies. Professional organizations recommend that women ages 25 to 29 years be screened with cytology alone, while women 30 years or older should be screened with cytology and HPV co-testing. Thus, the American Society for Colposcopy and Cervical Pathology (ASCCP) prefers that women ages 25 to 29 years are not managed based upon HPV results, even if an HPV test was performed at the time of screening. For women with ages 30 years or older and HPV positive, colposcopy must be performed.

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.

Levonorgestrel, also known as the morning-after pill, is a first-line oral emergency contraceptive pill with approval from the World Health Organization to prevent pregnancy. It is FDA-approved to be used within 72 hours of unprotected sexual intercourse or when a presumed contraceptive failure has occurred.

A prescription is not needed, and it is available over the counter at local pharmacies. The FDA has also approved levonorgestrel availability for all age groups due to its lack of life-threatening contraindications and side-effect profile.

There are several contraindications for the emergency contraceptive form, including allergy, hypersensitivity, severe liver disease, pregnancy, and drug-drug interactions with liver enzyme-inducing drugs. The medication is not for use in women confirmed to be pregnant; however, there is no proof nor reports of adverse effects on the mother or foetus following inadvertent exposure during pregnancy.

In the management of a miscarriage, after the completion of 7-14 days of expectant management, the woman is advised to take a pregnancy test after 3 weeks. In case of a positive result she is to return for further care.

After perineal repair, lactulose and a bulking agent should ideally be given for 5-10 days as well as broad spectrum antibiotics should be given that will cover all possible anaerobic bacteria. At 6-12 months a full evaluation should be done regarding the progress of healing. 60 to 80% of women are asymptomatic 12 months post delivery and external anal sphincter repair.