This woman has experienced a septic abortion. Therefore the first step is commencement of intensive antibiotic treatment as soon as cervical swabs have been taken.

The next step is evacuation of the uterus. Curettage can be performed after a few hours, to extract any remaining infected products of conception from the uterine cavity.

The choice of antibiotics depends on the most likely microorganism involved. Therefore, prior to commencing any other procedure, it is vital to take cervical swabs for microscopic examination to guide further antibiotic therapy (correct answer).

If curettage is performed immediately there is a risk that the infection would spread.

However, if Clostridium welchii infection is suspected from the cervical smear (particularly if encapsulation of the microorganisms is present), then curettage should be performed immediately along with commencing antibiotic treatment.

Curettage can be delayed for up to 12-24 hours if other microorganisms are suspected; unless a significant increase in bleeding occurs.

Ergometrine is not essential as an immediate treatment measure as the patient is not bleeding heavily and reports that her bleeding has decreased. However, ergometrine is commonly given when curettage is performed.

Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.

In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.

Magnesium Sulphate is the drug of choice in eclamptic patients. A loading dose of 4g magnesium sulphate in 100mL 0.9% saline IVI over 5min followed by maintenance IVI of 1g/h for 24h. Signs of toxicity include respiratory depression and jerky tendon reflexes. In recurrent fits additional 2g can be given. Magnesium should be stopped when the respiratory rate is <14/min, absent tendon reflexes, or urine output is <20mL/h.

Levator ani muscle is composed of three different muscles i.e. iliococcygeus, pubococcygeus and the puborectalis muscle. It is the main muscle that supports the organs of the pelvic cavity.
Bulbocavernosus and Ischiocavernosus muscles are located in-between the anus and scrotum and play an important role in sexual response in males.
Superficial and deep transverse perineal muscles are located in the perinium and pass in front of the anus.

A variety of changes in the cardiovascular system occur during normal pregnancy, including increases in cardiac output, arterial compliance, extracellular fluid volume and decreases in blood pressure (BP) and total peripheral resistance.

The risk of developing endometrial carcinoma is less than 5% over 20 years if the endometrium shows hyperplasia without atypia.
There are 2 types of Endometrial Hyperplasia:
1. Hyperplasia without atypia*
2. Atypical hyperplasia

Major Risk Factors:
Oestrogen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant)

Pelvic Outlet Boundaries Anteriorly: Pubic arch Laterally: Ischial tuberosities Posterolaterally: Inferior margin of the sacrotuberous ligament Posteriorly: Tip of the coccyx Note: The pelvis outlet is also called the inferior aperture. The pelvic brim is the superior aperture

Oxytocin acts via the G protein receptors and the calcium-calmodulin complex. It activates phospholipase C which produces IP3 to further trigger the calcium-calmodulin complex increasing intracellular Ca ion release.

Shoulder dystocia is a complication associated with fetal macrosomia and may result in neurological dysfunction. Fetal macrosomia is generally defined as birth weight – 4,000 g. It occurs in about 10% of pregnancies and one of the most important predictors of fetal macrosomia is previous macrosomic infant(s). The recurrence rate of fetal macrosomia is above 30%. Other risk factors are maternal diabetes, multiparity, prolonged gestation, maternal obesity, excessive weight gain, male foetus, and parental stature- Not all cases of fetal macrosomia lead to shoulder dystocia and the occurrence of this complication is only 0.5%-1% of all pregnancies.

To make clinical decision regarding management of the patient, it is important to understand that there are other factors that lead to shoulder dystocia, such as the mother’s anatomy. While statistics suggest that there’s a tendency to choose elective Caesarean delivery for suspected macrosomia, it is believed that most of procedures are unnecessary, as evidence has shown the number of complications are not reduce- Also while it is logical to consider induction of labour at the 37th week of pregnancy, it is associated with increased Caesarean deliveries because of failed inductions. The recommended course of action is watchful waiting till the patient goes in labour.

→ Induce labour at the 37th week of gestation is not the best course of action, as it is associated with high failure rate, which often leads to Caesarean delivery.
→ Schedule elective Caesarean delivery is considered unnecessary in patients who do not have diabetes. Statistics have shown no evidence that Caesarean delivery reduces the rate of complications.
→ Serial ultrasound for fetal weight estimation is incorrect. The strategies used to predict fetal macrosomia are risk factors, Leopold’s manoeuvres, and ultrasonography. Even when they are combined, they are considered inaccurate; much less ultrasonography alone.
→ At this point, blood glucose control in pregnancies associated with diabetes seems to have desired results in preventing macrosomia- A weight loss program is usually not recommended- Instead, expectant management should be considered.

Research suggests the risk of having preeclampsia again is approximately 20%, however experts cite a range from 5% to 80% depending on when you had it in a prior pregnancy, how severe it was, and additional risk factors you may have. If you had preeclampsia during your first pregnancy, you may get it again. HELLP is related to preeclampsia and about 4 to 12 percent of women diagnosed with preeclampsia develop HELLP. HELLP syndrome can also cause complications in pregnancy, and if you had HELLP in a previous pregnancy, regardless of the time of onset, you have a greater risk for developing it in future pregnancies.

Anti phospholipid syndrome is an autoimmune disorder in which abnormal antibodies are formed which increases the risk of blood clots to develop in vessels and leads to recurrent miscarriages to occurs. The changes of recurrent miscarriage in a previously known case of APL is 15%.

The clinical evaluation indicates that the patient is ovulating but has not started menstruating. These observations suggest that the pain she is experiencing on a monthly basis could be related to ovulation or there could be an obstruction preventing the flow of menstrual blood from the uterus.

Uterine or vaginal anomalies that can obstruct menstrual flow include imperforate hymen, absent vagina, a transverse vaginal septum, or cervical obstruction.

If the cause was an obstruction to the flow, the retained menstrual products would have developed into a suprapubic mass (hematometra/ haematocolpos). However, no palpable mass was detected on abdominal examination.

Mullerian (paramesonephric) agenesis (correct answer) is the only condition that would result in no endometrial development; consequently there was no palpable mass observed and no menstrual loss that could be shed was present. A pelvic (lower abdominal) ultrasound examination can confirm the diagnosis.

Twin pregnancies are at risk for iron deficiency due to significant maternal, fetal, and placental demands. Recommendations regarding the optimal iron dose in twin pregnancies are based on clinical expert opinions, advocating doubling the dose of iron from 30 mg of elemental iron to 60 mg routinely during the second and third trimester, regardless of maternal iron stores.

If pregnant with twins, patient should take the same prenatal vitamins she would take for any pregnancy, but a recommendation of extra folic acid and iron will be made. The additional folic acid and extra iron will help ward off iron-deficiency anaemia, which is more common when patient is pregnant with multiples.

Fetal crown-rump length (CRL) is recommended over last menstrual period for estimating GA when measured in early pregnancy i.e. before 9 to 13+6 weeks.

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.

An assessment of amniotic fluid in pregnancy can be done by taking ultrasound measurements of the depth of amniotic fluid pockets. The combination of the measurements in four quadrants is called the amniotic fluid index (AFI), one of the major determinants of the biophysical profile which predicts pregnancy outcome. An AFI of less than 5 cm, or less than the 5th percentile is defined as oligohydramnios while an AFI of more than 25 cm is considered polyhydramnios.

The use of anticoagulants during pregnancy is a complicated issue because warfarin is teratogenic if used in the first trimester, and is linked with fetal intracranial haemorrhage in the third trimester (mainly at doses 5 mg daily). Low molecular weight heparin may be insufficient at preventing thrombosis in women with mechanical prosthetic heart valves, where the risk of valve thrombus is 10 per cent. Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension, or artificial valve replacements, and in those in or at risk of atrial fibrillation. The options are either to continue warfarin for the pregnancy, or replace it with heparin between 6 and 12 weeks gestation to avoid the teratogenic risk. Warfarin should be started a week after delivery.

Haemoglobin decreases from 13.3 g/dL to 10.5 g/dL from the start of pregnancy i.e. First trimester till the 3rd trimester.

Maternal blood volume expands during pregnancy to allow adequate perfusion of vital organs, including the placenta and foetus, and to anticipate blood loss associated with delivery. The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. While there is some increase in intracellular water, the most marked expansion occurs in extracellular fluid volume, especially circulating plasma volume. This expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Overall, total body water increases from 6.5 to 8.5 L by the end of pregnancy.

Genital folds lead to the formation of the scrotum in males while in females they form the posterior labial commissure. Genital tubercles form the labia majora whereas the tubercle itself becomes the mons pubis. The labia minora is formed by the urogenital folds.

Mirena is a form of contraception also indicated for the treatment of heavy menstrual bleeding and the management of dysmenorrhea, being able to reduce the latter considerably.

Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

Venous thromboembolic disease (VTE) is the most common cause of direct maternal death in the UK. In the most recent triennium, there were 41 fatalities, giving a maternal mortality rate of 1.94 per 100 000 – more than twice that of the next most common cause, pre-eclampsia. As pregnancy is a hyper coagulable state. There are alterations in the fibrinolytics and thrombotic pathways. There is also an increased production of clotting factors during pregnancy.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor.

These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

All other options are incorrect.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.

Oxytocin binds to the G protein coupled receptors that triggers the IP3 mechanism leading to an elevated intracellular calcium ion.

The clinical picture demonstrated is most likely that of a ruptured ectopic pregnancy. The period of amenorrhea may point to pregnancy, while the past medical history of 2 recent terminations of pregnancy may indicate a failure of her current contraceptive method. Smoking cigarettes have been shown to not only decrease the efficacy of OCPs, but also serve as a known risk factor for ectopic pregnancy. The lady is unlikely to have endometritis as her last termination was over 6 months ago. The lack of fever helps to make appendicitis, PID and pyelonephritis less likely, though they are still possible.

Although uterine growth during the first few weeks of pregnancy is accomplished by increased numbers of smooth muscle cells (i.e. hyperplasia) and a smaller contribution from increased cell size (i.e. hypertrophy), the predominant growth of the uterus during pregnancy is by way of stretch‐induced myometrial hypertrophy. This ongoing process of stretch‐induced tissue remodelling and smooth muscle hypertrophy is accompanied by the lack of uterine contractions during most of gestation to accommodate the developing foetus (phase 0 of parturition). Phase 1 of parturition represents myometrial activation. The final stages of pregnancy are characterized by increases in spontaneous low‐amplitude contractions that gradually increase in frequency, rhythmicity and strength, normally culminating in labour and delivery of the foetus at term (phase 2 of parturition).

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus. It causes the formation of multiple ossification centres in the long bones. Resulting in stippled epiphyses and hence deform long bones.

The incubation period of varicella is 10-21 days.