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)

The pudendal nerve has its origins form S2, S3 and S4 spinal segments. It provides sensation to the clitoris and labia along with the ilioinguinal nerve.

During pregnancy, anaemia increases more than fourfold from the first to third trimester. It is a well established fact that there is a physiological drop in haemoglobin (Hb) in the mid trimester. This physiological drop is attributed to increase of plasma volume and hence decrease of blood viscosity lead to better circulation in placenta.

Afterpains may continue for 2-3 days (so none of the above). Breastfeeding may intensify pain due to stimulation of Oxytocin which causes uterine contractions

This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.

In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.

Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.

Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.

The cardinal ligament (or Mackenrodt’s ligament, lateral or transverse cervical ligament) is a major ligament of the uterus. It is located at the base of the broad ligament of the uterus. It attaches the cervix to the lateral pelvic wall by its attachment to the Obturator fascia of the Obturator internus muscle, and is continuous externally with the fibrous tissue that surrounds the pelvic blood vessels. It thus provides support to the uterus.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

Sigmoid colon is part of the hindgut and the hindgut is innervated by the T12-L1 segment of the spinal nerves.

Reduced fetal movements can be the first indication of possible fetal abnormalities. Movements are first perceived by the mother from about 18-20 weeks gestation, increase in size and frequency until 32 weeks gestation when they plateau at about 31 movements per hour. Investigations for reduced fetal heart rate include auscultation of the fetal heart rate using a handheld doppler device, and a cardiotocograph or ultrasound if the foetus is above 28 weeks gestation. About 70% of women who experience one episode of reduced fetal movement have uncomplicated pregnancies. They are advised to report to a maternal unit if another episode occurs.

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.

In a non pregnant adult female the cardiac output is 4.5L/min, by the 20 week of pregnancy the cardiac output increases by 40% to 6.3L/min. During early stages of labour it increases further still by 17% to 7.3L/min.

It is classified under type II hypersensitivity reaction. Antibodies are formed against the rhesus antigen i.e. D antigen. Hence when the Antibody reacts with the antigen on the RBC it results in activation of the complement cascade leading to lysis.

Oxygenation of fetal blood occurs in the placenta before it returns in the umbilical vein which joins the left branch of the portal vein. It bypasses the capillaries of the liver by going through the ductus venosus, which is obliterated after birth and becomes the ligamentum venosum. The oxygenated blood enters the inferior vena cava and is transported to the right atrium and
then through the patent foramen ovale to the left atrium and on to the left ventricle. From the left ventricle, the blood flows into the aorta and through the fetal vascular network. Blood returning from the head of the foetus passes through the superior vena cava to the right atrium and straight on to the right ventricle and pulmonary artery. However, it does not enter the pulmonary
circulation, being short-circuited by the ductus arteriosus to the aorta. Aortic blood is carried via the umbilical arteries back to the placenta for reoxygenation. At birth, the three short circuits, the ductus venosus, foramen ovale and ductus arteriosus, close.

Congenital Herpes Simplex Virus infection may cause high levels of morbidity and mortality in neonates. Risk of infection with HSV 1 and 2 is highest within 6 weeks of delivery and is transferred to the neonate via maternal secretions at birth. Affected babies can present as skin manifestations, CNS infection, or disseminated infection, which carries an 85% risk of mortality if left untreated. Treatment with high dose antivirals such as acyclovir can help decrease the case mortality rate to 30% in cases of disseminated infection.

Fibrinogen is activated by thrombin which converts it into fibrin which forms a mesh to trap red blood cells and form a clot.

If abnormal cells are found high up in the cervical canal, it is critical to consider doing a cone biopsy to rule out any cervical malignancy. A cone-shaped section of the cervix containing the abnormal cells is removed under general anaesthesia.
Loop Electrosurgical Excision Procedure is a way of removing the abnormal cells from the cervix using a wire loop. First a speculum is inserted to open the vagina so the uterus can be seen. Then a solution is applied to the surface of the cervix to make the areas of abnormal cells easier to see. It is done under local anaesthesia.

Cone biopsy is the only acceptable option to rule out malignancy. Cryotherapy, chemotherapy and radiotherapy are management options once malignancy has been confirmed.

Multiple studies have identified several risk factors for uterine atony such as polyhydramnios, fetal macrosomia, twin pregnancies, use of uterine inhibitors, history of uterine atony, multiparity, or prolonged labour.

TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.

Due to the previous history of caesarean section, uterine rupture would be the most likely cause of bleeding in this patient who is at a prolonged active phase of first stage of labour.

Maternal manifestations of uterine rupture are highly variable but some of its common features includes:
– Constant abdominal pain, where the pain may not be present in sufficient amount, character, or location suggestive of uterine rupture and may be masked partially or completely by use of regional analgesia.
– Signs of intra abdominal hemorrhage is a strong indication. Although hemorrhage is common feature, but signs and symptoms of intra-abdominal bleeding in cases of uterine rupture especially in those cases not associated with prior surgery may be subtle.
– Vaginal bleeding is not considered as a cardinal symptom as it may be modest, despite major intra-abdominal hemorrhage.
– Maternal tachycardia and hypotension
– Cessation of uterine contractions
– Loss of station of the fetal presenting part
– Uterine tenderness
As seen in this case, fetal bradycardia is the most common and characteristic clinical manifestation of uterine rupture, preceded by variable or late decelerations, but there is no other fetal heart rate pattern pathognomonic of rupture. Furthermore, fetal heart rate changes alone have a low sensitivity and specificity for diagnosing a case as uterine rupture.
Pain and persistent vaginal bleeding despite the use of uterotonic agents are characteristic for postpartum uterine rupture. If the rupture extends into the bladder hematuria may also occur.
A definite diagnosis of uterine rupture can be made only after laparotomy. Immediate cesarean section should be performed to save both the mother and the baby in cases where uterine rupture is suspected.

The pelvis is supported by a variety of ligaments. At term, these ligaments allow for variation in its structure such that the overall size of the pelvic cavity is increased in order to accommodate the upcoming foetus into the cavity.

Fetal ultrasound scanning is considered an essential part of routine antenatal care with first trimester scans recommended for confirming viability, accurate estimation of gestational age and determining the number of foetuses. Fetal crown-rump length (CRL) is measured in early pregnancy primarily to determine the gestation age (GA) of a foetus and is most reliable between 9+0 to 13+6 weeks’ gestation, but not beyond.

Yasmin has been linked to decreased fluid retention and weight gain as a side effect of COCs, which is why most women who experience this side effect prefer Yasmin®.
Due to its anti-mineralocorticoid properties, drospirenone, unlike earlier progestogens, is associated with no weight gain or even moderate weight loss.
Yasmin has a similar failure rate to other COCs. No evidence using Yasmin is linked to a lower risk of cervical cancer as a long-term side effect of COCs. Yasmin, like all COCs, can cause spotting and irregular bleeding in the first few months of use.
Drospirenone, a progesterone component, has antiandrogenic properties and is slightly more successful in treating acne, but the difference is not big enough to make it preferable in terms of acne therapy or prevention when compared to other COCs.

Neisseria Gonorrhoeae is a Gram negative diplococci.

This woman presents with a metastatic tumour of the ovary. Being from Australia is a hint in this question as the likely site of the primary tumour can vary depending on the country the patient is in and the availability of screening mammography. In underdeveloped countries, breast cancer is usually diagnosed later in life as screening mammography is generally not available, making the most likely site of the primary tumour in the breast. In Japan, where the incidence of stomach cancer is much higher than in western countries, the most likely primary site would be the stomach with a Krukenberg tumour in both ovaries. In Australia, mammographic screening is recommended every other year for all women over the age of 50, and so the most likely primary site would be the colon.

The most appropriate work-up to find the primary tumour in this patient would be performing a colonoscopy. A computed tomography (CT) of the abdomen may miss a small tumour, and an ultrasound examination would not be able to diagnosis a colon cancer. Mammography would be the correct response in under-developed countries. A lung malignancy would be detectable by chest X-ray, but would rarely cause a metastasis in the ovary.

Erb’s or Erb-Duchenne palsy is a type of brachial plexus injury. The brachial plexus comprises C5 to T1 nerve roots. In Erb’s palsy C5 and C6 are the roots primarily affected. Shoulder Dystocia is the most common cause of Erb’s palsy.

Urodynamics is a broad term that comprises cytometry, urethral pressure measurement, leak point pressure, pressure flow studies, EMG and videourodynamics. They assess the function of the bladder and urethra as a functional unit. This may provide information such as the site of bladder outlet obstruction, overactivity of the detrusor and sphincter weakness. In muscular terms the detrusor and sphincter muscles are being assessed.

Hysterosalpingography is a radiological test used to investigate infertility especially in patients with no history suggesting tubal blockages such as pelvic surgery or PID, in which case a laparoscopy and dye is better suited. For the procedure, a contrast dye is inserted through the cervix, flows through the uterus and the fallopian tubes and should spill into the peritoneum. Fluoroscopy provides dynamic images of these structures to determine if there are any abnormalities or blockages. HSG is best performed on day 6-12 in the cycle, after the cessation of menses, and before ovulation, to avoid X Ray exposure in case of an unknown early pregnancy.

Shoulder dystocia occurs when the fetal shoulder impacts on the maternal symphysis or sacrum during vaginal delivery. About 10% of babies with shoulder dystocia will suffer a brachial plexus injury, the most common one being Erb-Duchenne palsy. In Erb’s palsy, the upper nerve roots C5 and C6 are damaged due to excessive widening of the angle between the head and the shoulder. This causing temporary paralysis in the affected arm whereby the infant will present with its hand hanging limp by his side, internal rotation of the forearm, plus wrist and finger flexion. This sign is called the ‘waiter’s tip hand’. The palsy usually resolves spontaneously in a large proportion of cases.

The proximal attachment of the piriformis muscles is from the anterior surface of sacrum and it attaches distally to the superior border of the greater trochanter of the femur. It is innervated by the anterior rami of S1 and S2.