In high-risk pregnancies, continuous monitoring of foetal heart rate is considered mandatory.

However, in low-risk pregnancies, cardiotocograph (CTG) monitoring provides no benefits over intermittent auscultation.

A significant issue with CTG monitoring is that apparent abnormalities are identified that usually have minimal clinical significance, but can prompt the use of several obstetric interventions such as instrumental deliveries and Caesarean section. In low risk patients, such interventions may not even be required.

CTG monitoring has not been shown to reduce the incidence of cerebral palsy or other neonatal developmental abnormalities, nor does it accurately predict previous foetal oxygenation status unless the CTG is significantly abnormal when it is first connected.

Similarly, CTG cannot accurately predict current foetal oxygenation unless the readings are severely abnormal.

Therefore, there is no evidence to support routine admission CTG (correct answer).

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

Condition where there is insufficient fetal descent after pushing for ≥3 hours in nulliparous and ≥2 hours if multiparous women is defined as Second stage arrest of labor. Common risk factors for this presentation are maternal obesity, excessive weight gain during pregnancy and diabetes mellitus. Cephalopelvic disproportion, malposition, inadequate contractions and maternal exhaustion are the common etiologies of Second stage arrest of labor. Management includes Operative vaginal delivery or cesarean delivery as indicated in the case.

The second stage of labor begins with the dilatation of cervix to 10 cm and will end with fetal delivery. Parity and use of neuraxial anesthesia are the two factors which will affect the duration of second stage of labor and fetal station, which measures the descent of the fetal head through the pelvis determines its progression.

When there is no fetal descent after pushing for ≥3 hours or ≥2 hours in in nulliparous and multiparous patients respectively the condition is called an arrested second stage of labor. As her first delivery was a cesarean session due to breech presentation, this patient in the case is considered as nulliparous.

Most common cause of a protracted or arrested second stage is fetal malposition, which is the relation between the fetal presenting part to the maternal pelvis. Occiput anterior is the optimal fetal position as it facilitates the cardinal movements of labor, any deviations from this position like in occiput transverse position, can lead to cephalopelvic disproportion resulting in second stage arrest.
Inadequate contractions, that is less than 200 MVU averaged over 10 minutes, can lead to labor arrest but contractions are adequate in case of the patient mentioned.
Second stage arrest can be due to maternal obesity and excessive weight gain during pregnancy but this patient had a normal pre-pregnancy BMI of 20 kg/m2 and an appropriate weight gain of 15.9 kg 35 lb. So this also cannot be the reason.

Maternal expulsive efforts will change the fetal skull shape. This process called as molding helps to facilitate delivery by changing the fetal head into the shape of the pelvis. Whereas prolonged pressure on head can result in scalp edema which is called as caput, presence of both molding and caput suggest cephalopelvic disproportion, but is not suggestive of poor maternal effort.

Patients with a prior history of uterine myomectomy or cesarean delivery are at higher risk for uterine rupture.  In cases of uterine rupture, the patient will present with fetal heart rate abnormalities, sudden loss of fetal station (eg, going from +1 to −3 station) along with fetal retreat upward and into the abdominal cavity through the uterine scar due to decreased intrauterine pressure. In the given case patient’s fetal heart rate tracing is category 1 and fetal station has remained 0 which are non suggestive of uterine rupture.

When there is insufficient fetal descent after pushing ≥3 hours in nulliparous patients or ≥2 hours in multiparous patients is considered as second stage arrest of labor. The most common cause of second stage arrest is cephalopelvic disproportion, were the fetus presents in a nonocciput anterior position called as fetal malposition.

Mediolateral episiotomy is favoured to midline episiotomy because there is less extension of the incision and decreased chances of injury to the anal sphincter and rectum.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

The use of lamotrigine during pregnancy has not been associated with an increased risk of neural tube defects; however, the recommendation regarding higher doses of folic acid supplementation is often, but not always, broadened to include women taking any anticonvulsant, including lamotrigine.

The best method to provide symptomatic relief to this woman is to use pressure stockings and a vulval pad (correct answer). This will provide relief without causing any adverse effects.

In order to prevent ulceration, care is required to avoid trauma.

Since the patient is pregnant, surgical ligation or injecting of sclerosing solutions cannot be considered and are contraindicated.

Development of varices is often exacerbated in subsequent pregnancies; and therefore surgery should be eschewed until child-bearing is complete,

Bed rest in hospital would reduce the symptoms of the varicose veins; however this should be avoided as it can increase the risk of developing deep vein thrombosis.

Anticoagulant therapy has not been shown to be beneficial for treatment of varicosities that only affect the superficial venous system and should therefore not be used.

The presentation is antepartum haemorrhage. Ultrasound should be performed to find the reason for bleeding and assess the fetal well being.

Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

The best next line of management is to administer an oxytocic (Syntocinon) infusion.

This is because the progress of labour is slow, and it necessary to augment it. As the membranes have already ruptured, the next step is to increase the contractions and induce labour using an infusion of oxytocic (Syntocinon) infusion.

Extra fluid is also required, but this will be administered alongside the Syntocinon infusion.

A lumbar epidural block is indicated in patients with an occipito-posterior (OP) position. This should not be attempted until more pain relief is required and the progress of labour is reassessed.

A Caesarean section may be necessary due to obstructed labour or fetal distress, it is not indicated at this stage.

Taking blood and holding it in case cross-matching is ultimately required is common, but most patients do not have blood cross-matched prophylactically in case there is a need to be delivered by Caesarean section and require a transfusion.

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to rapid and severe haemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labour or rapid forceful labour, especially if stimulated.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

The correct answer is reassurance after thorough examination. Most breast lesions diagnosed during pregnancy and lactation, even some specific ones such as lactation and adenoma galactocele, are benign. The diagnosis of breast cancer, which is difficult to elucidate and is less common among women who are pregnant or lactating than among those of the same age who are not, continues to be a challenge for clinicians.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

The case is most likely diagnosed a threatened miscarriage.
A diagnosis of threatened miscarriage is made when there is uterine bleeding in the presence of a closed cervix and is confirmed by the sonographic visualisation of an intrauterine pregnancy with detectable fetal cardiac activity. Miscarriages may not always follow even though there was multiple episodes or large amounts of bleeding, therefore the term “threatened” is used in these cases.
At 7 to 11 weeks of gestation, about 90 to 96 percent cases of pregnancies, will not usually miscarry if they have presented with an intact fetal cardiac activity along with vaginal bleeding and if bleeding occurs at the later weeks of gestational age chances of success rate is higher.

Topic review:
– Inevitable miscarriages presents with a dilated cervix, increasing uterine bleeding and painful uterine contractions. The gestational tissues can often be felt or seen through the cervical os and its passage occurs within a short time.
– In Incomplete miscarriage, the membranes will rupture passing the fetus out, but significant amounts of placental tissue will be retained. This occurs most commonly in late first trimester or early second trimester. On examination, the cervical os will be opened and the gestational tissue can be observed in the cervix, with a uterine size smaller than expected for gestational age, but not well contracted. The amount of bleeding varies but can be severe enough to cause hypovolemic shock. There will be painful cramps
ontractions and ultrasound reveals tissue in the uterus.
– A missed miscarriage refers to the in-utero death of the embryo or fetus prior to 20th week of gestation, with retention of the pregnancy for a prolonged period of time. In this case, women may notice that symptoms associated with early pregnancy like nausea, breast tenderness, etc have abated and they don’t “feel pregnant” anymore.
Vaginal bleeding may occur but the cervix usually remains closed. Ultrasound reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.
– Complete miscarriage, usually occurs before 12 weeks of gestation and the entire contents of the uterus will be expelled resulting in a complete miscarriage. In this case, physical examination reveals a small, well contracted uterus with an open or closed cervix with scanty vaginal bleeding and mild cramping. Ultrasound will reveal an empty uterus with no extra-uterine gestation.

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.

Providers should identify any known risk factors for ectopic pregnancy in their patient’s history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment.

Performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy.

Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration.

Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. The patient may have a cervical ectopic pregnancy and would thus run the risk of haemorrhage and potential hemodynamic instability if a dilation and curettage are performed.

Pregnancy is considered as a hypercoagulable state with an increased risk for the development of conditions like deep venous thrombosis (DVT) and pulmonary embolism (PE). Among these two PE is the considered the most significant cause for maternal death in Australia.
A pregnant women with venous thromboembolism should be treated with heparin as warfarin is contraindicated. Warfarin should be avoided throughout pregnancy and especially during the first and third trimesters of pregnancy as it crosses the placenta. Intake of warfarin at 6-12 weeks of pregnancy can results in fetal warfarin syndrome which is characterised by:
– A characteristic nasal hypoplasia
– Short fingers with hypoplastic nails
– Calcified epiphyses, namely chondrodysplasia punctuta which is evident by stippling of epiphyses on X-ray.
– Intellectual disability
– Low birth weight
Recent studies show that the risk of fetal warfarin syndrome is around 5 % more in babies of women who require warfarin throughout pregnancy and the risk is always dose dependent.
Later exposure to warfarin, as in after 12 weeks, is mostly associated with central nervous system anomalies like microcephaly, hydrocephalus, agenesis of corpus callosum, Dandy-Walker malformation which is characterised by complete absence of cerebellar vermis along with enlarged fourth ventricle and mental retardation. Eye anomalies such as optic atrophy, microphthalmia, and Peter anomaly which is the dysgenesis of the anterior segment are also found in association. Newborns exposed to warfarin in all three trimesters are prone to present with blindness. Other complications found in neonates exposed to warfarin are perinatal intracranial hemorrhage and other major bleeding episodes.

Warfarin is not secreted into the breast milk and is so safe to use during the postpartum period.

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

The current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned caesarean section for delivery sometime after 39 weeks.

Pre-eclampsia presents with other features in addition to the presence of hypertension, also it’s diagnosis cannot be made considered peripheral edema as the only presenting symptom. Proteinuria occurs more commonly in pre-eclampsia than in gestational hypertension and the latter is mostly asymptomatic.

Hypertensive disorders are found to complicate about 10% of all pregnancies. Common one among them is Gestational hypertension, which is defined as the new onset of hypertension after 20 weeks of gestation without any maternal or fetal features of pre-eclampsia, in this case BP will return to normal within three months of postpartum.

Types of hypertensive disorders during pregnancy:
1. Pregnancy-induced hypertension:
a. Systolic blood pressure (SBP) above 140 mm of Hg and diastolic hypertension above 90 mmHg occurring for the first time after the 20th week of pregnancy, which regresses postpartum.
b. The rise in systolic blood pressure above 25 mm of Hg or diastolic blood pressure above 15 mm of Hg from readings before pregnancy or in the first trimester.
2. Mild pre-eclampsia:
BP up to 170/110 mm of Hg in the absence of associated features.
3. Severe pre-eclampsia:
BP above 170/110 mm of Hg and along with features such as kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise.
4. Essential (coincidental) hypertension:
Chronic underlying hypertension occurring before the onset of pregnancy or persisting after postpartum.
5. Pregnancy-aggravated hypertension:
Underlying hypertension which is worsened by pregnancy.

To diagnose pre-eclampsia clinically, presence of one or more of the following symptoms are required along with a history of onset of hypertension after 20 weeks of gestation.
– Proteinuria: Above 300 mg/24 h or urine protein
reatinine ratio more than 30 mg/mmol.
– Renal insufficiency: serum/plasma creatinine above 0.09 mmol/L or oliguria.
– Liver disease: raised serum transaminases and severe epigastric or right upper quadrant pain.
– Neurological problems: convulsions (eclampsia); hyperreflexia with clonus; severe headaches with hyperreflexia; persistent visual disturbances (scotomata).
– Haematological disturbances like thrombocytopenia; disseminated intravascular coagulation; hemolysis.

For this pregnant patient who recently travelled overseas most likely has a deep venous thrombosis (DVT). It would also be expected that the patient would have oedema in the symptomatic leg and account for the swelling described.

Though they could cause unilateral leg pain, neither symphyseal separation nor sciatica due to a prolapsed intervertebral disc usually occur as early as 18 weeks of gestation. This patient’s symptoms also do not suggest either diagnosis.

Pain due to trauma would usually be maximal at the site where the trauma took place, which would be in the knee for this patient. Traumatic pain and house cleaning also would not cause the pain described or result in ankle swelling.

This patient presents because of significant mood changes since she gave birth to her child: she is sad most of times and she is having guilt feelings about her adequacy for motherhood- She is also complaining of insomnia, tiredness, and even some suicidal ideation. These symptoms are highly suggestive postpartum depression. This should be differentiated from postpartum blues, which usually present within the first 2 weeks and last for few days. This patient’s symptoms started 5 weeks postpartum. Postpartum depression usually presents within the first 6 weeks to the first year postpartum.

Postpartum depression is the most common complication of childbearing and affects the mother, the child, and relationship with the partner. It is diagnosed the same way as major depressive disorder in other patients. Since untreated postpartum depression can have long-term effects on the mother and the child, appropriate therapy should be undertaken as soon as possible- Antidepressant medications such as sertraline can be used to treat postpartum depression. In a patient who has suicidal ideation, electroconvulsive therapy has a more rapid and effective action than medication and should be considered in these patients.

→ Cognitive behavioural therapy is effective in women with mild to moderate postpartum depression; it would not be a good choice in this patient with suicidal ideation and at risk of harming the baby.
→ Estrogen therapy used alone or in combination with antidepressant, has been shown to significantly reduce the symptoms of postpartum depression; however, it would not be the most appropriate choice in a patient with suicidal ideation.
→ Peer support has shown equivocal results in various studies even though most postpartum patients report that lacking an intimate friend or confidant or facing social isolation are factors leading to depression.
→ Non-directive counselling also known as ”listening visits“ has been found to be effective in postpartum patients, though the studies that were conducted are deemed to be of small sample and larger studies still need to be done to validate these findings. It would not be an appropriate choice for this patient with suicidal ideation.

Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.

The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.

The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.

As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.

Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.

Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.

The postpartum period begins soon after the baby’s delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state.

Bloody vaginal discharge (lochia rubra) is heavy for the first 3-4 days, and slowly it becomes watery in consistency and colour changes to pinkish-brown (lochia serosa). After the next 10-12 days, it changes to yellowish-white (lochia alba). Advise women to seek medical attention if heavy vaginal bleeding persists (soaking a pad or more in less than an hour). Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, rarely invasive placenta, or coagulation disorders. Endometritis may also occur, presenting as fever with no source, maybe accompanied by uterine tenderness and vaginal discharge. This usually requires intravenous antibiotics. This also should be explained and advise the mother to seek immediate medical attention.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, leading to shortness of breath, dizziness, fainting, and other symptoms, all of which are exacerbated by exertion. PH in pregnancy carries a 25–56% maternal mortality rate with a mixture of intrapartum and postpartum deaths.

Current recommendations for management of PH in pregnancy include termination of pregnancy if diagnosed early, or utilizing a controlled interventional approach with early nebulized prostanoid therapy and early elective caesarean section under regional anaesthesia. Other recommended therapies for peripartum management of PH include sildenafil and nitric oxide.

Complete abortion is defined as a ‘complete’ passage of all conception products.

The first day of the last menstrual period and findings on any prior ultrasounds should be determined to establish the gestational age and location of the pregnancy. An abdominal exam should be performed to assess for peritoneal signs that might indicate a ruptured ectopic pregnancy or extra-uterine extension of a septic abortion. Lastly, a pelvic exam is central to the evaluation of suspected miscarriage. It should include both speculum-facilitated visualization of the cervix and a bimanual examination to assess for cervical motion tenderness that may indicate a septic abortion or an adnexal mass that may herald ectopic pregnancy.

Early pregnancy loss takes many different forms. In missed abortion, there is asymptomatic or ‘missed’ death of the embryo or foetus without sufficient uterine contractions to push out the products of conception. In contrast, threatened abortion is characterized by symptomatic, ‘threatened’ expulsion of the products of conception, yet the cervical os remains closed, and the embryo or foetus remains viable.

Although there is a lack of consensus, complete abortion is often defined as the absence of a gestational sac on ultrasound with an endometrial stripe thickness of less than 30 mm.

Normal position of the foetus in relationship to the mother is always a longitudinal lie and a cephalic presentation. Transverse lie means that the baby is sideways. The foetus lies transverse till 26-28th week of gestation, after which it usually changes its position from transverse to a longitudinal lie with head down. A transverse lie can occur in conditions like grand multiparity, preterm foetus, placenta previa and pelvic contraction.

The given case scenario describes a typical case of measles in a pregnant woman, which is confirmed by serologic studies. Positive lgM in serology is suggestive of acute infection, while a negative lgG confirms that the infection is in early phase without any seroconversion.
Conservative management of the symptoms and its potential complications is the only management plan therapeutically available after contracting measles. ‘Notification’ and contact tracing are the other very important issues to be considered.
Measles is a notifiable disease and healthcare professionals are mandated on reporting all the identified cases of measles to the authorized public health units. The main objective of this notification is to conduct a contact tracing.

MMR vaccine is not useful once measles is contracted, as the vaccine is used for prevention of measles and as prophylaxis in post-exposure cases. For those with contact to a case of measles, MMR vaccine within 72 hours of contact may have a protective effect, but all measles-containing vaccines like MMR and MM RV are contraindicated throughout pregnancy even as prophylaxis.

As the circulating maternal antibodies will cross placenta and enters into the fetal circulation, a positive test does not confirm infection in the fetus. So serologic testing of the fetus is not useful.

NHIG is not useful in treating an established case of measles, as it is used as a post-measles exposure prophylactic for patients such as pregnant women, premature babies, etc who are contraindicated to MMR vaccine.

As both symptoms and lgM levels indicate measles infection, repeating measles-specific serologic test is not useful in this case. In general no test is indicated, unless its result has an impact on the further management of the case or any prognostic value.

Fetal heart rate tracings (FHR) under category I include all of the following:
– baseline rate 110– 160 bpm
– baseline FHR variability moderate
– accelerations present or absent
– late or variable decelerations absent
– early decelerations present or absent

The onset of fetal bleeding is marked by a tachycardia followed by a bradycardia with intermittent accelerations or decelerations. Small amounts of vaginal bleeding associated with FHR abnormalities should raise the suspicion of fetal haemorrhage. This condition demands prompt delivery and immediate reexpansion of the neonatal blood volume.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

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.